- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.66 / $173.66 / $173.66
| Facility | | $173.66 | $173.66 | $173.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.66 / $173.66 / $175.81
| Professional | | $173.66 | $173.66 | $175.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.24 / $182.24 / $182.24
| Facility | | $182.24 | $182.24 | $182.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.24 / $182.24 / $182.24
| Professional | | $182.24 | $182.24 | $182.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.66 / $182.24 / $217.08
| Facility | | $173.66 | $182.24 | $217.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.72 / $814.72 / $814.72
| Professional | | $814.72 | $814.72 | $814.72 |