- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.18 / $892.62 / $2,834.00
| Facility | | $164.18 | $892.62 | $2,834.00 |
- Facility/Professional
- Facility
- Modifier
- 25
- Low / Median / High Price
- $711.12 / $1,762.33 / $3,723.00
| Facility | 25 | $711.12 | $1,762.33 | $3,723.00 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $162.17 / $382.16 / $800.95
| Professional | 25 | $162.17 | $382.16 | $800.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,982.46 / $2,250.00 / $3,207.90
| Facility | | $1,982.46 | $2,250.00 | $3,207.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $429.63 / $1,382.50 / $2,651.00
| Facility | | $429.63 | $1,382.50 | $2,651.00 |