- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.50 / $3.50 / $3.50
| Facility | | $3.50 | $3.50 | $3.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.50 / $10.57 / $10.83
| Professional | | $3.50 | $10.57 | $10.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.70 / $22.35 / $24.95
| Professional | | $16.70 | $22.35 | $24.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.63 / $11.74 / $14.53
| Professional | | $11.63 | $11.74 | $14.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.50 / $10.50 / $75.00
| Facility | | $3.50 | $10.50 | $75.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.10 / $5.55 / $13.31
| Professional | | $2.10 | $5.55 | $13.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.10 / $5.55 / $10.00
| Professional | | $2.10 | $5.55 | $10.00 |