- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Facility | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.66 / $129.66 / $162.08
| Professional | | $129.66 | $129.66 | $162.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Facility | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Professional | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.66 / $151.69 / $186.39
| Facility | | $129.66 | $151.69 | $186.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $165.32
| Professional | | $162.08 | $162.08 | $165.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $182.45
| Professional | | $162.08 | $162.08 | $182.45 |