- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,907.00 / $6,907.00 / $6,907.00
| Facility | | $6,907.00 | $6,907.00 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.02 / $156.60 / $261.39
| Professional | | $135.02 | $156.60 | $261.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $640.00 / $640.00 / $640.00
| Facility | | $640.00 | $640.00 | $640.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.74 / $124.23 / $227.04
| Professional | | $96.74 | $124.23 | $227.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.30 / $232.74 / $629.28
| Professional | | $51.30 | $232.74 | $629.28 |