- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $123.03 / $123.03
| Facility | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $123.03 / $295.12
| Professional | | $100.00 | $123.03 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $295.12 / $1,412.54
| Facility | | $257.04 | $295.12 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $204.17 / $295.12
| Professional | | $112.20 | $204.17 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $165.96 / $501.19
| Facility | | $165.96 | $165.96 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $251.19 / $251.19
| Professional | | $204.17 | $251.19 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.04 / $165.96 / $199.53
| Facility | | $138.04 | $165.96 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $147.91
| Professional | | $102.33 | $102.33 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.18 / $4,897.79 / $9,772.37
| Facility | | $83.18 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $380.19
| Professional | | $251.19 | $251.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $295.12 / $1,412.54
| Facility | | $257.04 | $295.12 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $204.17 / $323.59
| Professional | | $117.49 | $204.17 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.18 / $165.96 / $302.00
| Facility | | $0.18 | $165.96 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $165.96 / $251.19
| Professional | | $112.20 | $165.96 | $251.19 |