- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.68 / $203.68 / $203.68
| Facility | | $203.68 | $203.68 | $203.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.49 / $148.40 / $203.68
| Professional | | $145.49 | $148.40 | $203.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.25 / $137.25 / $145.49
| Facility | | $137.25 | $137.25 | $145.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.49 / $145.49 / $145.49
| Professional | | $145.49 | $145.49 | $145.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.10 / $194.64 / $216.00
| Facility | | $130.10 | $194.64 | $216.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.55 / $127.55 / $516.39
| Professional | | $127.55 | $127.55 | $516.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.49 / $145.49 / $210.96
| Professional | | $145.49 | $145.49 | $210.96 |