- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.54 / $197.54 / $557.24
| Facility | | $197.54 | $197.54 | $557.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.84 / $197.54 / $197.54
| Professional | | $172.84 | $197.54 | $197.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.62 / $458.60 / $648.54
| Facility | | $187.62 | $458.60 | $648.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.54 / $283.73 / $354.66
| Professional | | $197.54 | $283.73 | $354.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.15 / $197.54 / $246.92
| Facility | | $148.15 | $197.54 | $246.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.50 / $246.92 / $246.92
| Professional | | $160.50 | $246.92 | $246.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.25 / $123.46 / $246.92
| Professional | | $110.25 | $123.46 | $246.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $429.64 / $1,172.86 / $1,172.86
| Facility | | $429.64 | $1,172.86 | $1,172.86 |