- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.86 / $75.86 / $8,500.00
| Facility | | $75.86 | $75.86 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $106.93 / $106.93
| Professional | | $75.86 | $106.93 | $106.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.88 / $129.84 / $163.13
| Professional | | $103.88 | $129.84 | $163.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.86 / $128.96 / $227.58
| Facility | | $75.86 | $128.96 | $227.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.76 / $203.20 / $244.45
| Professional | | $123.76 | $203.20 | $244.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.18 / $207.78 / $296.14
| Professional | | $124.18 | $207.78 | $296.14 |