- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.55 / $172.55 / $172.55
| Facility | | $172.55 | $172.55 | $172.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $174.76 / $200.71
| Professional | | $173.03 | $174.76 | $200.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.79 / $217.40 / $217.40
| Professional | | $184.79 | $217.40 | $217.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.24 / $163.24 / $163.24
| Facility | | $163.24 | $163.24 | $163.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $212.21 / $244.85
| Professional | | $173.03 | $212.21 | $244.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $173.03 / $173.03
| Professional | | $173.03 | $173.03 | $173.03 |