- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.56 / $287.56 / $7,968.00
| Facility | | $287.56 | $287.56 | $7,968.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.56 / $287.56 / $287.56
| Professional | | $287.56 | $287.56 | $287.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.56 / $287.56 / $416.96
| Facility | | $287.56 | $287.56 | $416.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $713.00 / $2,417.00 / $4,102.00
| Facility | | $713.00 | $2,417.00 | $4,102.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |