- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,747.14 / $2,747.14 / $2,747.14
| Professional | | $2,747.14 | $2,747.14 | $2,747.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,549.06 / $1,549.06 / $1,549.06
| Facility | | $1,549.06 | $1,549.06 | $1,549.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.81 / $1,549.06 / $1,595.53
| Professional | | $1,130.81 | $1,549.06 | $1,595.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $757.80 / $757.80 / $757.80
| Facility | | $757.80 | $757.80 | $757.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,443.92 / $3,046.56 / $4,810.35
| Professional | | $2,443.92 | $3,046.56 | $4,810.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $757.80 / $757.80 / $1,549.06
| Facility | | $757.80 | $757.80 | $1,549.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.81 / $1,595.53 / $2,986.02
| Professional | | $1,130.81 | $1,595.53 | $2,986.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.97 / $3,066.46 / $3,999.74
| Professional | | $1,549.97 | $3,066.46 | $3,999.74 |