- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Facility | | $101.03 | $101.03 | $101.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $108.34
| Professional | | $101.03 | $101.03 | $108.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.32 / $547.60 / $547.60
| Facility | | $174.32 | $547.60 | $547.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $466.64
| Professional | | $101.03 | $101.03 | $466.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Facility | | $101.03 | $101.03 | $101.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Professional | | $101.03 | $101.03 | $101.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.03 / $151.80 / $8,090.00
| Facility | | $101.03 | $151.80 | $8,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Professional | | $101.03 | $101.03 | $101.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $101.03
| Professional | | $101.03 | $101.03 | $101.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $174.32 / $547.60 / $547.60
| Facility | | $174.32 | $547.60 | $547.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $466.64
| Professional | | $101.03 | $101.03 | $466.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.03 / $101.03 / $194.99
| Professional | | $101.03 | $101.03 | $194.99 |