- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.44 / $144.66 / $275.72
| Facility | | $131.44 | $144.66 | $275.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.47 / $133.47 / $215.98
| Professional | | $133.47 | $133.47 | $215.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.13 / $131.13 / $131.13
| Professional | | $131.13 | $131.13 | $131.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.98 / $190.88 / $229.25
| Facility | | $166.98 | $190.88 | $229.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.08 / $138.15 / $140.50
| Professional | | $117.08 | $138.15 | $140.50 |