- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $168.09 / $168.09
| Professional | | $161.62 | $168.09 | $168.09 |
- 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
- $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 / $161.62
| Professional | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Professional | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $168.09 / $168.09
| Professional | | $161.62 | $168.09 | $168.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $234.35
| Professional | | $161.62 | $161.62 | $234.35 |