- 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 / $157.69 / $161.50
| Professional | | $152.00 | $157.69 | $161.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.75 / $162.60 / $162.60
| Facility | | $156.75 | $162.60 | $162.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.60 / $162.60 / $162.60
| Professional | | $162.60 | $162.60 | $162.60 |
- 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
- $150.76 / $167.51 / $172.54
| Professional | | $150.76 | $167.51 | $172.54 |