- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.16 / $54.44 / $161.75
| Facility | | $2.16 | $54.44 | $161.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.86 / $1.86 / $2.34
| Professional | | $1.86 | $1.86 | $2.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.85 / $2.09 / $2.40
| Facility | | $1.85 | $2.09 | $2.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.86 / $1.86 / $1.86
| Professional | | $1.86 | $1.86 | $1.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.33 / $1.79 / $3.34
| Professional | | $1.33 | $1.79 | $3.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.04 / $2.52 / $2.65
| Professional | | $2.04 | $2.52 | $2.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.86 / $1.86 / $1.86
| Professional | | $1.86 | $1.86 | $1.86 |