- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.44 / $139.44 / $141.68
| Facility | | $139.44 | $139.44 | $141.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.98 / $141.68 / $206.41
| Professional | | $127.98 | $141.68 | $206.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.25 / $165.28 / $229.60
| Professional | | $132.25 | $165.28 | $229.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.79 / $206.33 / $305.37
| Professional | | $150.79 | $206.33 | $305.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.55 / $171.82 / $295.57
| Professional | | $141.55 | $171.82 | $295.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.19 / $142.68 / $217.98
| Professional | | $130.19 | $142.68 | $217.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.31 / $192.50 / $270.52
| Professional | | $151.31 | $192.50 | $270.52 |