- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.72 / $97.72 / $97.72
| Facility | | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $128.82 / $309.03
| Professional | | $97.72 | $128.82 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $229.09 / $1,412.54
| Facility | | $199.53 | $229.09 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $173.78 / $229.09
| Professional | | $102.33 | $173.78 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $398.11
| Facility | | $128.82 | $128.82 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $199.53 / $199.53
| Professional | | $147.91 | $199.53 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $165.96 / $194.98
| Facility | | $128.82 | $165.96 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $194.98
| Professional | | $141.25 | $141.25 | $194.98 |
- 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
- $194.98 / $194.98 / $302.00
| Professional | | $194.98 | $194.98 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $144.54
| Professional | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $229.09 / $1,412.54
| Facility | | $199.53 | $229.09 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $173.78 / $309.03
| Professional | | $102.33 | $173.78 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.18 / $169.82 / $309.03
| Facility | | $0.18 | $169.82 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $162.18 / $194.98
| Professional | | $97.72 | $162.18 | $194.98 |