- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.26 / $168.34 / $172.40
| Professional | | $162.26 | $168.34 | $172.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.40 / $179.16 / $189.30
| Facility | | $172.40 | $179.16 | $189.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.54 / $182.54 / $182.54
| Professional | | $182.54 | $182.54 | $182.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $172.40
| Facility | | $172.40 | $172.40 | $172.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $172.40
| Professional | | $172.40 | $172.40 | $172.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.82 / $202.82 / $202.82
| Professional | | $202.82 | $202.82 | $202.82 |