- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.62 / $164.84 / $166.47
| Facility | | $161.62 | $164.84 | $166.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $177.79
| Professional | | $161.62 | $161.62 | $177.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $311.93
| Facility | | $161.62 | $161.62 | $311.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $164.84
| Professional | | $161.62 | $161.62 | $164.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.04 / $161.62 / $161.62
| Facility | | $157.04 | $161.62 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $175.35
| Professional | | $161.62 | $161.62 | $175.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $193.94
| Professional | | $161.62 | $161.62 | $193.94 |