- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.23 / $5.35 / $5.35
| Professional | | $2.23 | $5.35 | $5.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.52 / $2.60 / $2.68
| Facility | | $2.52 | $2.60 | $2.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.89 / $2.21 / $3.60
| Professional | | $1.89 | $2.21 | $3.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.26 / $2.77 / $5.35
| Facility | | $1.26 | $2.77 | $5.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.55 / $3.74 / $3.94
| Professional | | $3.55 | $3.74 | $3.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.83 / $3.94 / $6.90
| Professional | | $2.83 | $3.94 | $6.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.76 / $2.76 / $4.13
| Professional | | $2.76 | $2.76 | $4.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.80 / $1.87 / $2.81
| Professional | | $1.80 | $1.87 | $2.81 |