- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.61 / $655.61 / $8,229.00
| Facility | | $655.61 | $655.61 | $8,229.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.61 / $655.61 / $1,383.34
| Professional | | $655.61 | $655.61 | $1,383.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.68 / $6.68 / $6.68
| Professional | | $6.68 | $6.68 | $6.68 |
- 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
- $523.00 / $1,450.00 / $5,301.00
| Facility | | $523.00 | $1,450.00 | $5,301.00 |