- 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
- $2.17 / $2.17 / $2.64
| Professional | | $2.17 | $2.17 | $2.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.25 / $2.27 / $2.81
| Professional | | $2.25 | $2.27 | $2.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.84 / $3.25 / $4.46
| Facility | | $1.84 | $3.25 | $4.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.75 / $2.16 / $3.78
| Professional | | $0.75 | $2.16 | $3.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.52 / $2.98 / $3.47
| Facility | | $2.52 | $2.98 | $3.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.72 / $3.47 / $5.64
| Professional | | $2.72 | $3.47 | $5.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.94 / $2.25 / $2.65
| Professional | | $1.94 | $2.25 | $2.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.75 / $1.98 / $5.04
| Professional | | $0.75 | $1.98 | $5.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.71 / $2.71 / $2.71
| Professional | | $2.71 | $2.71 | $2.71 |