- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.73 / $131.73 / $139.50
| Facility | | $131.73 | $131.73 | $139.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.26 / $126.43 / $164.40
| Professional | | $100.26 | $126.43 | $164.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.37 / $199.28 / $288.04
| Facility | | $189.37 | $199.28 | $288.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.32 / $159.02 / $167.30
| Professional | | $112.32 | $159.02 | $167.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.68 / $130.68 / $171.51
| Facility | | $130.68 | $130.68 | $171.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.08 / $130.68 / $239.28
| Professional | | $111.08 | $130.68 | $239.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.48 / $109.47 / $170.69
| Professional | | $79.48 | $109.47 | $170.69 |