- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $533.80 / $533.80 / $533.80
| Facility | | $533.80 | $533.80 | $533.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $172.47
| Professional | | $164.25 | $164.25 | $172.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.94 / $163.21 / $172.44
| Facility | | $161.94 | $163.21 | $172.44 |
- 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 / $164.25
| Professional | | $164.25 | $164.25 | $164.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $182.84
| Professional | | $164.25 | $164.25 | $182.84 |