- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $158.56
| Facility | | $158.56 | $158.56 | $158.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.83 / $154.83 / $158.56
| Professional | | $154.83 | $154.83 | $158.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.10 / $155.10 / $155.10
| Facility | | $155.10 | $155.10 | $155.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.10 / $155.10 / $155.10
| Professional | | $155.10 | $155.10 | $155.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.92 / $158.56 / $158.56
| Facility | | $53.92 | $158.56 | $158.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $158.56
| Professional | | $158.56 | $158.56 | $158.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.32 / $155.44 / $155.44
| Professional | | $138.32 | $155.44 | $155.44 |