- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.82 / $161.82 / $2,290.00
| Facility | | $161.82 | $161.82 | $2,290.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.61 / $161.82 / $161.82
| Professional | | $158.61 | $161.82 | $161.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.94 / $251.94 / $251.94
| Professional | | $251.94 | $251.94 | $251.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.01 / $260.27 / $434.59
| Facility | | $154.01 | $260.27 | $434.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.02 / $381.38 / $1,236.56
| Professional | | $173.02 | $381.38 | $1,236.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.65 / $272.25 / $380.57
| Facility | | $190.65 | $272.25 | $380.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.94 / $277.06 / $320.82
| Professional | | $251.94 | $277.06 | $320.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.69 / $341.35 / $401.58
| Professional | | $190.69 | $341.35 | $401.58 |