- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.41 / $110.41 / $110.41
| Facility | | $110.41 | $110.41 | $110.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.40 / $110.41 / $140.32
| Professional | | $110.40 | $110.41 | $140.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,832.04 / $6,056.77 / $9,643.85
| Facility | | $3,832.04 | $6,056.77 | $9,643.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.00 / $130.00 / $130.00
| Professional | | $130.00 | $130.00 | $130.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.41 / $117.29 / $189.63
| Facility | | $110.41 | $117.29 | $189.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.50 / $203.58 / $850.03
| Professional | | $113.50 | $203.58 | $850.03 |