- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Professional | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.47 / $191.23 / $318.72
| Facility | | $152.47 | $191.23 | $318.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $318.72
| Professional | | $161.62 | $161.62 | $318.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.47 / $191.23 / $318.72
| Facility | | $152.47 | $191.23 | $318.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $318.72
| Professional | | $161.62 | $161.62 | $318.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $484.86
| Professional | | $161.62 | $161.62 | $484.86 |