- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.35 / $2.35 / $3.00
| Facility | | $2.35 | $2.35 | $3.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.35 / $2.35 / $3.15
| Professional | | $2.35 | $2.35 | $3.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.13 / $2.13 / $2.83
| Professional | | $2.13 | $2.13 | $2.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.01 / $3.01 / $3.04
| Professional | | $3.01 | $3.01 | $3.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.67 / $2.67 / $3.30
| Facility | | $2.67 | $2.67 | $3.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.27 / $2.27 / $3.30
| Professional | | $2.27 | $2.27 | $3.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.33 / $3.80 / $5.32
| Professional | | $3.33 | $3.80 | $5.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.22 / $2.66 / $4.66
| Facility | | $1.22 | $2.66 | $4.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $5.00 / $6.34
| Professional | | $3.00 | $5.00 | $6.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.50 / $3.01 / $5.58
| Facility | | $2.50 | $3.01 | $5.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.50 / $3.01 / $5.58
| Professional | | $2.50 | $3.01 | $5.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.62 / $1.90 / $3.16
| Professional | | $1.62 | $1.90 | $3.16 |