- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Facility | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $163.24
| Professional | | $161.62 | $161.62 | $163.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.76 / $163.95 / $177.54
| Professional | | $145.76 | $163.95 | $177.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.14 / $274.14 / $315.27
| Facility | | $274.14 | $274.14 | $315.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.13 / $173.85 / $215.16
| Professional | | $172.13 | $173.85 | $215.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.84 / $206.21 / $290.92
| Facility | | $164.84 | $206.21 | $290.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.84 / $164.84 / $184.62
| Professional | | $164.84 | $164.84 | $184.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $181.01
| Professional | | $161.62 | $161.62 | $181.01 |