- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.00 / $450.00 / $450.00
| Facility | | $450.00 | $450.00 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.00 / $450.00 / $562.50
| Professional | | $450.00 | $450.00 | $562.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,462.08 / $2,462.08 / $2,462.08
| Facility | | $2,462.08 | $2,462.08 | $2,462.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.45 / $556.96 / $981.96
| Facility | | $540.45 | $556.96 | $981.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.45 / $674.91 / $981.96
| Professional | | $540.45 | $674.91 | $981.96 |