- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.74 / $140.13 / $142.90
| Facility | | $138.74 | $140.13 | $142.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $140.13 / $166.49
| Professional | | $138.74 | $140.13 | $166.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $119.89 / $154.49 / $200.63
| Facility | | $119.89 | $154.49 | $200.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.01 / $150.01 / $153.01
| Professional | | $150.01 | $150.01 | $153.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $121.37 / $121.37 / $121.37
| Facility | | $121.37 | $121.37 | $121.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.88 / $130.88 / $138.74
| Facility | | $130.88 | $130.88 | $138.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $138.74
| Professional | | $138.74 | $138.74 | $138.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $138.74 / $239.70
| Professional | | $131.83 | $138.74 | $239.70 |