- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.88 / $177.26 / $177.26
| Facility | | $143.88 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.88 / $173.09 / $177.26
| Professional | | $143.88 | $173.09 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.95 / $198.11 / $428.10
| Professional | | $172.95 | $198.11 | $428.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Facility | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Professional | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Professional | | $177.26 | $177.26 | $177.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $597.00
| Facility | | $177.26 | $177.26 | $597.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $177.26 / $177.26
| Professional | | $177.26 | $177.26 | $177.26 |