- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.54 / $186.54 / $261.16
| Facility | | $186.54 | $186.54 | $261.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.54 / $186.54 / $186.54
| Professional | | $186.54 | $186.54 | $186.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.16 / $145.16 / $217.76
| Facility | | $145.16 | $145.16 | $217.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.16 / $145.16 / $148.07
| Professional | | $145.16 | $145.16 | $148.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $158.56
| Facility | | $158.56 | $158.56 | $158.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $158.56
| Professional | | $158.56 | $158.56 | $158.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.34 / $155.44 / $171.38
| Professional | | $152.34 | $155.44 | $171.38 |