- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,908.26 / $1,908.26 / $1,908.26
| Facility | | $1,908.26 | $1,908.26 | $1,908.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,908.26 / $1,908.26 / $2,501.75
| Professional | | $1,908.26 | $1,908.26 | $2,501.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,300.60 / $4,300.60 / $4,300.60
| Facility | | $4,300.60 | $4,300.60 | $4,300.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,300.60 / $4,300.60 / $4,300.60
| Professional | | $4,300.60 | $4,300.60 | $4,300.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $80.00 / $100.00
| Facility | | $64.00 | $80.00 | $100.00 |