- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.63 / $50.63 / $50.63
| Facility | | $50.63 | $50.63 | $50.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.17 / $43.69 / $50.63
| Professional | | $29.17 | $43.69 | $50.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.58 / $234.58 / $234.58
| Facility | | $234.58 | $234.58 | $234.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.77 / $308.77 / $308.77
| Facility | | $308.77 | $308.77 | $308.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.19 / $35.19 / $47.05
| Professional | | $35.19 | $35.19 | $47.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.71 / $49.60 / $84.16
| Professional | | $35.71 | $49.60 | $84.16 |