- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.21 / $163.21 / $163.21
| Facility | | $163.21 | $163.21 | $163.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $165.90 / $190.53
| Professional | | $164.25 | $165.90 | $190.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.94 / $190.52 / $190.52
| Professional | | $161.94 | $190.52 | $190.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.96 / $154.96 / $154.96
| Facility | | $154.96 | $154.96 | $154.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $201.44 / $232.43
| Professional | | $164.25 | $201.44 | $232.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.25 / $164.25 / $164.25
| Professional | | $164.25 | $164.25 | $164.25 |