- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.37 / $140.37 / $140.37
| Facility | | $140.37 | $140.37 | $140.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.62 / $2.62 / $2.62
| Professional | | $2.62 | $2.62 | $2.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.36 / $1.71 / $4.47
| Facility | | $1.36 | $1.71 | $4.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.61 / $2.61 / $2.61
| Professional | | $2.61 | $2.61 | $2.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.62 / $2.62 / $2.62
| Facility | | $2.62 | $2.62 | $2.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.62 / $2.62 / $2.62
| Professional | | $2.62 | $2.62 | $2.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.62 / $2.62 / $3.17
| Professional | | $2.62 | $2.62 | $3.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $140.37 / $140.37 / $140.37
| Facility | | $140.37 | $140.37 | $140.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.62 / $2.62 / $2.62
| Professional | | $2.62 | $2.62 | $2.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.57 / $2.57 / $3.86
| Professional | | $2.57 | $2.57 | $3.86 |