- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.00 / $174.00 / $174.00
| Facility | | $174.00 | $174.00 | $174.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.90 / $174.00 / $174.00
| Professional | | $147.90 | $174.00 | $174.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.90 / $147.90 / $147.90
| Professional | | $147.90 | $147.90 | $147.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.47 / $235.25 / $294.06
| Facility | | $48.47 | $235.25 | $294.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.00 / $145.00 / $661.20
| Professional | | $145.00 | $145.00 | $661.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.15 / $174.15 / $174.15
| Professional | | $174.15 | $174.15 | $174.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.90 / $147.90 / $147.90
| Professional | | $147.90 | $147.90 | $147.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.00 / $145.00 / $159.50
| Professional | | $145.00 | $145.00 | $159.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.00 / $145.00 / $145.00
| Facility | | $145.00 | $145.00 | $145.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.00 / $145.00 / $145.00
| Professional | | $145.00 | $145.00 | $145.00 |