- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.09 / $173.09 / $177.26
| Facility | | $173.09 | $173.09 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.83 / $173.09 / $177.26
| Professional | | $166.83 | $173.09 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $179.03
| Professional | | $177.26 | $177.26 | $179.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Facility | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Professional | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.97 / $208.54 / $208.54
| Professional | | $145.97 | $208.54 | $208.54 |