- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.31 / $156.50 / $309.55
| Facility | | $143.31 | $156.50 | $309.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Professional | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $134.88
| Professional | | $134.88 | $134.88 | $134.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Facility | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Professional | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $168.60 / $168.60 / $218.26
| Facility | | $168.60 | $168.60 | $218.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.47 / $140.50 / $179.84
| Facility | | $133.47 | $140.50 | $179.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.47 / $140.50 / $179.84
| Professional | | $133.47 | $140.50 | $179.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.22 / $140.50 / $168.60
| Professional | | $138.22 | $140.50 | $168.60 |