- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.47 / $167.05 / $174.72
| Facility | | $159.47 | $167.05 | $174.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $146.16 / $167.05
| Professional | | $139.21 | $146.16 | $167.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.44 / $150.44 / $150.44
| Facility | | $150.44 | $150.44 | $150.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.35 / $150.44 / $150.44
| Professional | | $141.35 | $150.44 | $150.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.08 / $136.43 / $139.21
| Facility | | $116.08 | $136.43 | $139.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.21 / $139.21 / $151.03
| Professional | | $139.21 | $139.21 | $151.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.94 / $139.21 / $178.19
| Professional | | $136.94 | $139.21 | $178.19 |