- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.25 / $2.25 / $5.30
| Facility | | $2.25 | $2.25 | $5.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.25 / $2.25 / $2.25
| Professional | | $2.25 | $2.25 | $2.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.14 / $5.14 / $872.10
| Facility | | $5.14 | $5.14 | $872.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.65 / $2.65 / $3.98
| Professional | | $2.65 | $2.65 | $3.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.84 / $3.38 / $7.21
| Facility | | $2.84 | $3.38 | $7.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.65 / $2.65 / $2.65
| Facility | | $2.65 | $2.65 | $2.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.65 / $2.65 / $2.65
| Professional | | $2.65 | $2.65 | $2.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.14 / $5.14 / $872.10
| Facility | | $5.14 | $5.14 | $872.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.65 / $2.65 / $3.98
| Professional | | $2.65 | $2.65 | $3.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.65 / $2.65 / $3.71
| Professional | | $2.65 | $2.65 | $3.71 |