- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.23 / $30.23 / $2,697.30
| Facility | | $30.23 | $30.23 | $2,697.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.23 / $30.23 / $31.44
| Professional | | $30.23 | $30.23 | $31.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.22 / $31.89 / $134.55
| Facility | | $27.22 | $31.89 | $134.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.23 / $30.37 / $2,212.73
| Professional | | $30.23 | $30.37 | $2,212.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.44 / $37.11 / $68.17
| Facility | | $32.44 | $37.11 | $68.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.23 / $30.23 / $30.23
| Facility | | $30.23 | $30.23 | $30.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.23 / $30.23 / $33.06
| Professional | | $30.23 | $30.23 | $33.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.83 / $53.00 / $8,090.00
| Facility | | $30.83 | $53.00 | $8,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.23 / $30.23 / $30.23
| Professional | | $30.23 | $30.23 | $30.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.23 / $30.23 / $30.23
| Professional | | $30.23 | $30.23 | $30.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,917.38 / $3,208.44 / $3,208.44
| Facility | | $2,917.38 | $3,208.44 | $3,208.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $75.00 / $134.55
| Facility | | $75.00 | $75.00 | $134.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.23 / $30.23 / $2,212.73
| Professional | | $30.23 | $30.23 | $2,212.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.23 / $30.23 / $50.00
| Professional | | $30.23 | $30.23 | $50.00 |