- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $358.07
| Facility | | $204.61 | $204.61 | $358.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $246.34
| Professional | | $204.61 | $204.61 | $246.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.07 / $548.35 / $1,023.05
| Facility | | $200.07 | $548.35 | $1,023.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.69 / $204.61 / $235.30
| Professional | | $163.69 | $204.61 | $235.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.34 / $251.26 / $556.54
| Facility | | $219.34 | $251.26 | $556.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $204.61
| Facility | | $204.61 | $204.61 | $204.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $261.38
| Professional | | $204.61 | $204.61 | $261.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.61 / $308.43 / $8,090.00
| Facility | | $204.61 | $308.43 | $8,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.36 / $195.36 / $390.72
| Professional | | $195.36 | $195.36 | $390.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,060.68 / $3,060.68 / $3,060.68
| Facility | | $3,060.68 | $3,060.68 | $3,060.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $272.17 / $1,023.05 / $1,023.05
| Facility | | $272.17 | $1,023.05 | $1,023.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.84 / $204.61 / $274.02
| Professional | | $81.84 | $204.61 | $274.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.84 / $204.61 / $216.89
| Professional | | $81.84 | $204.61 | $216.89 |