- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.74 / $156.74 / $244.91
| Facility | | $156.74 | $156.74 | $244.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.13 / $234.27 / $259.25
| Professional | | $147.13 | $234.27 | $259.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $216.74 / $216.74 / $216.74
| Facility | | $216.74 | $216.74 | $216.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.74 / $216.74 / $216.74
| Professional | | $216.74 | $216.74 | $216.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.77 / $174.77 / $174.77
| Facility | | $174.77 | $174.77 | $174.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.58 / $127.58 / $174.77
| Professional | | $127.58 | $127.58 | $174.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.02 / $139.54 / $215.02
| Professional | | $93.02 | $139.54 | $215.02 |