- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $624.94 / $624.94 / $63,100.60
| Facility | | $624.94 | $624.94 | $63,100.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.94 / $2,443.12 / $2,443.12
| Professional | | $624.94 | $2,443.12 | $2,443.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $624.94 / $624.94 / $624.94
| Facility | | $624.94 | $624.94 | $624.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.94 / $624.94 / $624.94
| Professional | | $624.94 | $624.94 | $624.94 |