- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.61 / $5.61 / $6.05
| Facility | | $5.61 | $5.61 | $6.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.52 / $2.90 / $2.90
| Professional | | $2.52 | $2.90 | $2.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.34 / $2.94 / $7.67
| Facility | | $2.34 | $2.94 | $7.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.42 / $2.42 / $2.42
| Professional | | $2.42 | $2.42 | $2.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.42 / $2.42 / $2.42
| Facility | | $2.42 | $2.42 | $2.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.42 / $2.42 / $2.42
| Professional | | $2.42 | $2.42 | $2.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.42 / $2.42 / $2.93
| Professional | | $2.42 | $2.42 | $2.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.61 / $5.61 / $6.05
| Facility | | $5.61 | $5.61 | $6.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.52 / $2.90 / $6.05
| Professional | | $2.52 | $2.90 | $6.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.42 / $2.42 / $3.63
| Professional | | $2.42 | $2.42 | $3.63 |