- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.49 / $169.19 / $170.23
| Facility | | $161.49 | $169.19 | $170.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.99 / $140.99 / $169.19
| Professional | | $140.99 | $140.99 | $169.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.35 / $152.35 / $152.35
| Facility | | $152.35 | $152.35 | $152.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.32 / $152.35 / $152.35
| Professional | | $139.32 | $152.35 | $152.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.01 / $140.99 / $140.99
| Facility | | $133.01 | $140.99 | $140.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.99 / $140.99 / $140.99
| Professional | | $140.99 | $140.99 | $140.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.99 / $149.44 / $180.47
| Professional | | $140.99 | $149.44 | $180.47 |