- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.02 / $3.02 / $3.02
| Facility | | $3.02 | $3.02 | $3.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.02 / $3.98 / $6.03
| Professional | | $3.02 | $3.98 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.25 / $6.03 / $7.24
| Professional | | $5.25 | $6.03 | $7.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $8.13 / $10.00
| Professional | | $5.01 | $8.13 | $10.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.55 / $5.13 / $13.80
| Facility | | $3.55 | $5.13 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.80 / $3.80 / $9.33
| Professional | | $3.80 | $3.80 | $9.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.79 / $4.79 / $5.37
| Professional | | $4.79 | $4.79 | $5.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.55 / $6.03 / $12.59
| Facility | | $3.55 | $6.03 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.57 / $2.57 / $2.63
| Professional | | $2.57 | $2.57 | $2.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.37 / $5.37 / $30.20
| Professional | | $5.37 | $5.37 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.25 / $6.03 / $10.96
| Facility | | $5.25 | $6.03 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.16 / $3.98 / $6.03
| Professional | | $3.16 | $3.98 | $6.03 |