- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.60 / $164.60 / $164.60
| Facility | | $164.60 | $164.60 | $164.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.59 / $164.60 / $181.06
| Professional | | $164.59 | $164.60 | $181.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.03 / $43.72 / $58.82
| Facility | | $36.03 | $43.72 | $58.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.62 / $156.62 / $156.62
| Professional | | $156.62 | $156.62 | $156.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.41 / $175.41 / $175.41
| Facility | | $175.41 | $175.41 | $175.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.41 / $175.41 / $175.41
| Professional | | $175.41 | $175.41 | $175.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.69 / $177.07 / $187.09
| Professional | | $156.69 | $177.07 | $187.09 |