- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.04 / $61.04 / $65.78
| Facility | | $61.04 | $61.04 | $65.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.36 / $22.36 / $22.36
| Professional | | $22.36 | $22.36 | $22.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.03 / $0.03 / $0.03
| Facility | | $0.03 | $0.03 | $0.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $21.05
| Professional | | $21.05 | $21.05 | $21.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $21.05
| Facility | | $21.05 | $21.05 | $21.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $21.05
| Professional | | $21.05 | $21.05 | $21.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $25.49
| Professional | | $21.05 | $21.05 | $25.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.04 / $61.04 / $65.78
| Facility | | $61.04 | $61.04 | $65.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.36 / $22.36 / $65.78
| Professional | | $22.36 | $22.36 | $65.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.05 / $21.05 / $30.52
| Professional | | $21.05 | $21.05 | $30.52 |