- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.00 / $2,480.00 / $2,480.00
| Professional | | $2,480.00 | $2,480.00 | $2,480.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.00 / $80.00 / $80.00
| Facility | | $80.00 | $80.00 | $80.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,480.00 / $2,480.00 / $3,348.00
| Facility | | $2,480.00 | $2,480.00 | $3,348.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,480.00 / $2,490.00 / $3,112.50
| Facility | | $2,480.00 | $2,490.00 | $3,112.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,988.00 / $3,112.50 / $2,250,000.00
| Professional | | $2,988.00 | $3,112.50 | $2,250,000.00 |