- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,209.31 / $1,209.31 / $1,750.36
| Facility | | $1,209.31 | $1,209.31 | $1,750.36 |
- Facility/Professional
- Facility
- Modifier
- 25
- Low / Median / High Price
- $935.09 / $1,147.31 / $2,626.08
| Facility | 25 | $935.09 | $1,147.31 | $2,626.08 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $162.21 / $162.21 / $548.00
| Professional | 25 | $162.21 | $162.21 | $548.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,601.96 / $5,601.96 / $5,601.96
| Facility | | $5,601.96 | $5,601.96 | $5,601.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,601.96 / $5,601.96 / $5,601.96
| Facility | | $5,601.96 | $5,601.96 | $5,601.96 |