- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,174.90 / $1,862.09
| Facility | | $776.25 | $1,174.90 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $2,290.87
| Professional | | $1,621.81 | $1,949.84 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $14,454.40 / $45,708.82
| Facility | | $14,454.40 | $14,454.40 | $45,708.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $4,677.35
| Professional | | $4,677.35 | $4,677.35 | $4,677.35 |