- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.26 / $146.26 / $228.53
| Facility | | $146.26 | $146.26 | $228.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.26 / $227.12 / $291.47
| Professional | | $146.26 | $227.12 | $291.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.25 / $202.25 / $202.25
| Facility | | $202.25 | $202.25 | $202.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.25 / $202.25 / $202.25
| Professional | | $202.25 | $202.25 | $202.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.10 / $225.10 / $225.10
| Facility | | $225.10 | $225.10 | $225.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.32 / $164.32 / $225.10
| Professional | | $164.32 | $164.32 | $225.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $82.93 / $172.06 / $200.64
| Facility | | $82.93 | $172.06 | $200.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.80 / $130.21 / $200.64
| Professional | | $86.80 | $130.21 | $200.64 |