- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $1.82 / $3.63
| Facility | | $1.00 | $1.82 | $3.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $2.00
| Professional | | $1.00 | $1.00 | $2.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.09 / $2.14 / $3.47
| Facility | | $2.09 | $2.14 | $3.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.55 / $1.82 / $1.82
| Professional | | $1.55 | $1.82 | $1.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.86 / $1.86 / $2.95
| Facility | | $1.86 | $1.86 | $2.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.86 / $1.95 / $2.57
| Professional | | $1.86 | $1.95 | $2.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.82 / $85.11 / $85.11
| Facility | | $1.82 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.82 / $7.94 / $7.94
| Professional | | $1.82 | $7.94 | $7.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.82 / $1.82 / $1.82
| Professional | | $1.82 | $1.82 | $1.82 |