- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.30 / $30.30 / $32.65
| Facility | | $30.30 | $30.30 | $32.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.58 / $13.78 / $13.78
| Professional | | $13.58 | $13.78 | $13.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.38 / $40.38 / $40.38
| Facility | | $40.38 | $40.38 | $40.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.06 / $13.06 / $13.06
| Professional | | $13.06 | $13.06 | $13.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.06 / $13.06 / $13.06
| Facility | | $13.06 | $13.06 | $13.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.06 / $13.06 / $13.06
| Professional | | $13.06 | $13.06 | $13.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.06 / $13.06 / $15.82
| Professional | | $13.06 | $13.06 | $15.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.30 / $30.30 / $32.65
| Facility | | $30.30 | $30.30 | $32.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.58 / $13.78 / $32.65
| Professional | | $13.58 | $13.78 | $32.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.06 / $13.06 / $19.59
| Professional | | $13.06 | $13.06 | $19.59 |