- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.42 / $164.42 / $182.51
| Facility | | $164.42 | $164.42 | $182.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.42 / $164.42 / $182.51
| Professional | | $164.42 | $164.42 | $182.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.12 / $163.12 / $163.12
| Facility | | $163.12 | $163.12 | $163.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.56 / $219.62 / $219.62
| Facility | | $204.56 | $219.62 | $219.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.62 / $219.62 / $219.62
| Professional | | $219.62 | $219.62 | $219.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.42 / $185.79 / $235.16
| Professional | | $164.42 | $185.79 | $235.16 |