- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $4,265.80 / $6,165.95
| Facility | | $100.00 | $4,265.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $107.15 / $3,388.44
| Professional | | $97.72 | $107.15 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $112.20 / $186.21
| Facility | | $100.00 | $112.20 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $112.20 / $239.88
| Professional | | $100.00 | $112.20 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $100.00 / $100.00
| Facility | | $93.33 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $123.03 / $4,365.16
| Facility | | $100.00 | $123.03 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $109.65 / $123.03
| Professional | | $100.00 | $109.65 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $186.21 / $416.87
| Facility | | $102.33 | $186.21 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $117.49 / $117.49
| Professional | | $107.15 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $79.43
| Professional | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $109.65
| Professional | | $100.00 | $100.00 | $109.65 |