- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.42 / $164.42 / $164.42
| Facility | | $164.42 | $164.42 | $164.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.41 / $164.42 / $180.86
| Professional | | $164.41 | $164.42 | $180.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.09 / $177.29 / $238.52
| Facility | | $146.09 | $177.29 | $238.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.09 / $196.09 / $196.09
| Professional | | $196.09 | $196.09 | $196.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.62 / $219.62 / $219.62
| Facility | | $219.62 | $219.62 | $219.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.62 / $219.62 / $267.26
| Professional | | $219.62 | $219.62 | $267.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.42 / $185.79 / $235.16
| Professional | | $164.42 | $185.79 | $235.16 |