- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $7,285.42
| Facility | | $245.30 | $245.30 | $7,285.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $269.83
| Professional | | $245.30 | $245.30 | $269.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.30 / $326.30 / $1,071.67
| Facility | | $326.30 | $326.30 | $1,071.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $1,071.67
| Professional | | $245.30 | $245.30 | $1,071.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $382.20 / $440.04 / $561.36
| Facility | | $382.20 | $440.04 | $561.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Facility | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Professional | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.30 / $368.56 / $8,090.00
| Facility | | $245.30 | $368.56 | $8,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Professional | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $245.30
| Professional | | $245.30 | $245.30 | $245.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.30 / $326.30 / $1,071.67
| Facility | | $326.30 | $326.30 | $1,071.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $1,071.67
| Professional | | $245.30 | $245.30 | $1,071.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.30 / $245.30 / $423.06
| Professional | | $245.30 | $245.30 | $423.06 |