- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.17 / $2.17 / $2.17
| Facility | | $2.17 | $2.17 | $2.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.39 / $2.17 / $2.17
| Professional | | $1.39 | $2.17 | $2.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.41 / $2.52 / $2.54
| Professional | | $2.41 | $2.52 | $2.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.80 / $3.75 / $6.53
| Professional | | $2.80 | $3.75 | $6.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.95 / $3.69 / $4.78
| Facility | | $1.95 | $3.69 | $4.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $1.31 / $2.77
| Professional | | $1.00 | $1.31 | $2.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.87 / $3.36 / $5.51
| Facility | | $2.87 | $3.36 | $5.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.61 / $3.32 / $5.69
| Professional | | $2.61 | $3.32 | $5.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.30 / $4.00 / $5.20
| Professional | | $3.30 | $4.00 | $5.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.87 / $1.31 / $2.06
| Professional | | $0.87 | $1.31 | $2.06 |