- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.60 / $153.60 / $479.23
| Facility | | $153.60 | $153.60 | $479.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.60 / $153.60 / $153.60
| Professional | | $153.60 | $153.60 | $153.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.19 / $163.19 / $163.19
| Professional | | $163.19 | $163.19 | $163.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.60 / $192.00 / $427.39
| Facility | | $153.60 | $192.00 | $427.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.60 / $169.60 / $203.52
| Professional | | $153.60 | $169.60 | $203.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.00 / $160.00 / $169.74
| Professional | | $160.00 | $160.00 | $169.74 |