- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.65 / $134.94 / $187.13
| Facility | | $131.65 | $134.94 | $187.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.45 / $113.57 / $134.94
| Professional | | $112.45 | $113.57 | $134.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.20 / $124.20 / $124.20
| Facility | | $124.20 | $124.20 | $124.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.20 / $124.20 / $133.57
| Professional | | $124.20 | $124.20 | $133.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.09 / $112.45 / $143.76
| Facility | | $106.09 | $112.45 | $143.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.45 / $112.45 / $112.45
| Professional | | $112.45 | $112.45 | $112.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.45 / $112.45 / $367.84
| Professional | | $112.45 | $112.45 | $367.84 |