- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.77 / $140.83 / $143.91
| Facility | | $134.77 | $140.83 | $143.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.36 / $140.63 / $140.83
| Professional | | $117.36 | $140.63 | $140.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.14 / $127.14 / $127.14
| Facility | | $127.14 | $127.14 | $127.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.87 / $127.14 / $127.14
| Professional | | $120.87 | $127.14 | $127.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.72 / $117.36 / $117.36
| Facility | | $110.72 | $117.36 | $117.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.36 / $117.36 / $117.36
| Professional | | $117.36 | $117.36 | $117.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.41 / $117.36 / $117.36
| Professional | | $116.41 | $117.36 | $117.36 |