- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.50 / $161.50 / $161.50
| Facility | | $161.50 | $161.50 | $161.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.00 / $161.50 / $161.50
| Professional | | $152.00 | $161.50 | $161.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.50 / $161.50 / $161.50
| Facility | | $161.50 | $161.50 | $161.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.50 / $161.50 / $161.50
| Professional | | $161.50 | $161.50 | $161.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.72 / $167.51 / $167.51
| Professional | | $145.72 | $167.51 | $167.51 |