- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.52 / $155.52 / $309.49
| Facility | | $155.52 | $155.52 | $309.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.52 / $155.52 / $155.52
| Professional | | $155.52 | $155.52 | $155.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.19 / $163.19 / $163.19
| Facility | | $163.19 | $163.19 | $163.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.19 / $163.19 / $163.19
| Professional | | $163.19 | $163.19 | $163.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.52 / $182.40 / $831.15
| Facility | | $155.52 | $182.40 | $831.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.00 / $160.00 / $160.00
| Professional | | $160.00 | $160.00 | $160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.00 / $160.00 / $160.00
| Professional | | $160.00 | $160.00 | $160.00 |