- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $1,452.25
| Professional | | $1,452.25 | $1,452.25 | $1,452.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.05 / $1,862.25 / $3,103.76
| Facility | | $1,370.05 | $1,862.25 | $3,103.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $3,103.76
| Professional | | $1,452.25 | $1,452.25 | $3,103.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,370.05 / $1,862.25 / $3,103.76
| Facility | | $1,370.05 | $1,862.25 | $3,103.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $3,103.76
| Professional | | $1,452.25 | $1,452.25 | $3,103.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.25 / $1,452.25 / $4,356.75
| Professional | | $1,452.25 | $1,452.25 | $4,356.75 |