- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $93.33 / $194.98
| Professional | | $77.62 | $93.33 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $186.21 / $1,000.00
| Facility | | $162.18 | $186.21 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $138.04 / $186.21
| Professional | | $85.11 | $138.04 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $316.23
| Facility | | $104.71 | $104.71 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $162.18 / $162.18
| Professional | | $117.49 | $162.18 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $112.20 / $125.89
| Facility | | $104.71 | $112.20 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $83.18 / $128.82
| Professional | | $83.18 | $83.18 | $128.82 |
- 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
- $158.49 / $158.49 / $239.88
| Professional | | $158.49 | $158.49 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Professional | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $186.21 / $1,000.00
| Facility | | $162.18 | $186.21 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $141.25 / $213.80
| Professional | | $87.10 | $141.25 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.14 / $131.83 / $239.88
| Facility | | $0.14 | $131.83 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $125.89 / $158.49
| Professional | | $79.43 | $125.89 | $158.49 |