- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.85 / $132.85 / $177.18
| Facility | | $132.85 | $132.85 | $177.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.56 / $135.13 / $177.19
| Professional | | $110.56 | $135.13 | $177.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.09 / $153.61 / $196.73
| Professional | | $117.09 | $153.61 | $196.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.40 / $200.24 / $324.26
| Professional | | $147.40 | $200.24 | $324.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.84 / $168.53 / $264.85
| Professional | | $126.84 | $168.53 | $264.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.06 / $141.88 / $178.35
| Professional | | $118.06 | $141.88 | $178.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.22 / $234.03 / $302.63
| Professional | | $146.22 | $234.03 | $302.63 |