- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.34 / $89.34 / $9,101.04
| Facility | | $89.34 | $89.34 | $9,101.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $89.34 / $125.50
| Professional | | $89.34 | $89.34 | $125.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.68 / $239.43 / $588.60
| Facility | | $125.68 | $239.43 | $588.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $93.81 / $1,160.52
| Professional | | $89.34 | $93.81 | $1,160.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.77 / $109.71 / $213.17
| Facility | | $95.77 | $109.71 | $213.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.34 / $89.34 / $133.32
| Facility | | $89.34 | $89.34 | $133.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $89.34 / $109.60
| Professional | | $89.34 | $89.34 | $109.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.34 / $165.24 / $8,090.00
| Facility | | $89.34 | $165.24 | $8,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $89.34 / $89.34
| Professional | | $89.34 | $89.34 | $89.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $89.34 / $103.40
| Professional | | $89.34 | $89.34 | $103.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,644.61 / $1,644.61 / $1,943.62
| Facility | | $1,644.61 | $1,644.61 | $1,943.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.07 / $588.60 / $588.60
| Facility | | $131.07 | $588.60 | $588.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $94.70 / $1,160.52
| Professional | | $89.34 | $94.70 | $1,160.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.34 / $93.81 / $128.29
| Professional | | $89.34 | $93.81 | $128.29 |