- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.94 / $101.94 / $101.94
| Facility | | $101.94 | $101.94 | $101.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.94 / $128.25 / $270.00
| Professional | | $101.94 | $128.25 | $270.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.60 / $485.27 / $1,113.14
| Facility | | $159.60 | $485.27 | $1,113.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.73 / $167.00 / $227.83
| Professional | | $96.73 | $167.00 | $227.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $254.74 / $301.27 / $387.98
| Facility | | $254.74 | $301.27 | $387.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.55 / $152.55 / $153.72
| Facility | | $152.55 | $152.55 | $153.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.36 / $152.55 / $245.89
| Professional | | $111.36 | $152.55 | $245.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.43 / $4,618.00 / $9,239.00
| Facility | | $83.43 | $4,618.00 | $9,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.90 / $188.90 / $198.34
| Professional | | $188.90 | $188.90 | $198.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.43 / $136.12 / $148.54
| Facility | | $111.43 | $136.12 | $148.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.12 / $148.54 / $148.54
| Professional | | $136.12 | $148.54 | $148.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $485.27 / $1,113.14 / $1,113.14
| Facility | | $485.27 | $1,113.14 | $1,113.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.78 / $116.39 / $227.83
| Professional | | $88.78 | $116.39 | $227.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.74 / $208.74 / $208.74
| Professional | | $208.74 | $208.74 | $208.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.29 / $124.73 / $227.83
| Professional | | $90.29 | $124.73 | $227.83 |