- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.88 / $2.86 / $4.50
| Facility | | $1.88 | $2.86 | $4.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.34 / $2.34 / $3.21
| Professional | | $2.34 | $2.34 | $3.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.50 / $4.38 / $5.88
| Facility | | $2.50 | $4.38 | $5.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.94 / $1.94 / $2.50
| Professional | | $1.94 | $1.94 | $2.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.50 / $2.65 / $2.65
| Facility | | $2.50 | $2.65 | $2.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.65 / $2.65 / $3.37
| Professional | | $2.65 | $2.65 | $3.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.34 / $3.17 / $3.71
| Facility | | $2.34 | $3.17 | $3.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.33 / $1.33 / $1.33
| Professional | | $1.33 | $1.33 | $1.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.66 / $2.66 / $4.12
| Professional | | $2.66 | $2.66 | $4.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $100.00 / $100.00
| Facility | | $75.00 | $100.00 | $100.00 |