- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.21 / $163.21 / $164.25
| Facility | | $163.21 | $163.21 | $164.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $197.10
| Professional | | $164.25 | $164.25 | $197.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,177.85 / $6,283.58 / $8,453.43
| Facility | | $5,177.85 | $6,283.58 | $8,453.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $164.25
| Professional | | $164.25 | $164.25 | $164.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $164.25
| Facility | | $164.25 | $164.25 | $164.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $190.52
| Professional | | $164.25 | $164.25 | $190.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.61 / $164.25 / $180.68
| Professional | | $139.61 | $164.25 | $180.68 |