- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $164.84
| Facility | | $161.62 | $161.62 | $164.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $166.47
| Professional | | $161.62 | $161.62 | $166.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Facility | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Professional | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.47 / $152.47 / $161.62
| Facility | | $152.47 | $152.47 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Professional | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.84 / $171.32 / $274.11
| Facility | | $164.84 | $171.32 | $274.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.17 / $177.79 / $226.27
| Professional | | $176.17 | $177.79 | $226.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Professional | | $161.62 | $161.62 | $161.62 |