- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.55 / $174.55 / $174.55
| Facility | | $174.55 | $174.55 | $174.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.24 / $174.55 / $174.55
| Professional | | $163.24 | $174.55 | $174.55 |
- 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
- $97.50 / $178.02 / $446.65
| Facility | | $97.50 | $178.02 | $446.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.41 / $164.84 / $1,697.27
| Professional | | $158.41 | $164.84 | $1,697.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $179.07
| Professional | | $161.62 | $161.62 | $179.07 |