- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.27 / $3.58 / $5.68
| Facility | | $2.27 | $3.58 | $5.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.27 / $3.54 / $3.65
| Professional | | $2.27 | $3.54 | $3.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.67 / $3.67 / $5.51
| Facility | | $3.67 | $3.67 | $5.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.67 / $3.67 / $3.74
| Professional | | $3.67 | $3.67 | $3.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $40.00
| Facility | | $40.00 | $40.00 | $40.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.34 / $3.34 / $3.54
| Facility | | $3.34 | $3.34 | $3.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.54 / $3.54 / $3.54
| Professional | | $3.54 | $3.54 | $3.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.54 / $3.54 / $7.40
| Professional | | $3.54 | $3.54 | $7.40 |