- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $2,028.92
| Facility | | $158.56 | $158.56 | $2,028.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $202.96
| Professional | | $158.56 | $158.56 | $202.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.25 / $145.25 / $145.25
| Professional | | $145.25 | $145.25 | $145.25 |
- 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
- $46.73 / $67.28 / $146.46
| Professional | | $46.73 | $67.28 | $146.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.44 / $155.44 / $164.78
| Professional | | $155.44 | $155.44 | $164.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.96 / $51.96 / $51.96
| Professional | | $51.96 | $51.96 | $51.96 |