- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $172.40
| Professional | | $172.40 | $172.40 | $172.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.66 / $209.20 / $545.77
| Facility | | $166.66 | $209.20 | $545.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.02 / $172.39 / $172.39
| Professional | | $169.02 | $172.39 | $172.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $172.40
| Facility | | $172.40 | $172.40 | $172.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $310.32
| Professional | | $172.40 | $172.40 | $310.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $174.12
| Professional | | $172.40 | $172.40 | $174.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $172.40 / $172.40
| Professional | | $172.40 | $172.40 | $172.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.40 / $202.82 / $304.23
| Professional | | $172.40 | $202.82 | $304.23 |