- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.02 / $4,542.00 / $9,288.00
| Facility | | $237.02 | $4,542.00 | $9,288.00 |
- Facility/Professional
- Facility
- Modifier
- 25
- Low / Median / High Price
- $2,457.60 / $8,736.39 / $9,756.44
| Facility | 25 | $2,457.60 | $8,736.39 | $9,756.44 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $171.30 / $476.28 / $719.39
| Professional | 25 | $171.30 | $476.28 | $719.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,594.43 / $3,594.43 / $3,594.43
| Facility | | $3,594.43 | $3,594.43 | $3,594.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.71 / $225.89 / $285.89
| Facility | | $156.71 | $225.89 | $285.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.15 / $260.00 / $428.83
| Professional | | $194.15 | $260.00 | $428.83 |