- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.25 / $10.25 / $10.25
| Facility | | $10.25 | $10.25 | $10.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.77 / $9.66 / $10.25
| Professional | | $8.77 | $9.66 | $10.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.35 / $21.10 / $24.14
| Facility | | $16.35 | $21.10 | $24.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.78 / $11.78 / $11.78
| Professional | | $11.78 | $11.78 | $11.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.40 / $13.40 / $13.40
| Facility | | $13.40 | $13.40 | $13.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.77 / $9.77 / $13.40
| Professional | | $9.77 | $9.77 | $13.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.72 / $13.72 / $13.72
| Facility | | $13.72 | $13.72 | $13.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.12 / $13.72 / $18.57
| Professional | | $13.12 | $13.72 | $18.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.88 / $11.88 / $11.88
| Professional | | $11.88 | $11.88 | $11.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.60 / $7.60 / $9.11
| Facility | | $7.60 | $7.60 | $9.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.03 / $10.52 / $17.54
| Professional | | $8.03 | $10.52 | $17.54 |