- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.28 / $575.28 / $575.28
| Facility | | $575.28 | $575.28 | $575.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $566.24 / $575.28 / $575.28
| Professional | | $566.24 | $575.28 | $575.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $60.00 / $85.00
| Professional | | $50.00 | $60.00 | $85.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.28 / $575.28 / $575.28
| Facility | | $575.28 | $575.28 | $575.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.00 / $750.00 / $2,400,000.00
| Professional | | $750.00 | $750.00 | $2,400,000.00 |