- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.50 / $125.50 / $139.31
| Facility | | $125.50 | $125.50 | $139.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.50 / $125.50 / $139.31
| Professional | | $125.50 | $125.50 | $139.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.58 / $128.58 / $141.44
| Facility | | $128.58 | $128.58 | $141.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.19 / $137.94 / $137.94
| Facility | | $131.19 | $137.94 | $137.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.94 / $137.94 / $137.94
| Professional | | $137.94 | $137.94 | $137.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $17.00 / $20.00
| Professional | | $17.00 | $17.00 | $20.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.65 / $147.65 / $170.18
| Professional | | $147.65 | $147.65 | $170.18 |