- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,248.07 / $7,943.28
| Facility | | $3,890.45 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,981.07
| Professional | | $3,890.45 | $3,890.45 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $6,025.60 / $6,025.60
| Professional | | $151.36 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $14,125.38 / $25,118.86
| Facility | | $4,677.35 | $14,125.38 | $25,118.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $12,882.50 / $25,118.86
| Facility | | $8,511.38 | $12,882.50 | $25,118.86 |