- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.00 / $630.00 / $630.00
| Professional | | $630.00 | $630.00 | $630.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,051.59 / $1,051.59 / $1,051.59
| Facility | | $1,051.59 | $1,051.59 | $1,051.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.59 / $1,051.59 / $1,051.59
| Professional | | $1,051.59 | $1,051.59 | $1,051.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $590.84 / $590.84
| Facility | | $100.00 | $590.84 | $590.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.84 / $590.84 / $590.84
| Professional | | $590.84 | $590.84 | $590.84 |