- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.50 / $750.00 / $1,800.00
| Facility | | $562.50 | $750.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.00 / $555.00 / $562.50
| Professional | | $555.00 | $555.00 | $562.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $487.50 / $487.50 / $2,003.63
| Facility | | $487.50 | $487.50 | $2,003.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.93 / $861.93 / $1,077.41
| Professional | | $861.93 | $861.93 | $1,077.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.00 / $600.00 / $2,512.50
| Facility | | $450.00 | $600.00 | $2,512.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.00 / $315.00 / $750.00
| Professional | | $315.00 | $315.00 | $750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.00 / $315.00 / $450.00
| Professional | | $315.00 | $315.00 | $450.00 |