- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.72 / $754.67 / $3,091.00
| Facility | | $139.72 | $754.67 | $3,091.00 |
- Facility/Professional
- Facility
- Modifier
- 25
- Low / Median / High Price
- $960.96 / $1,508.43 / $2,848.13
| Facility | 25 | $960.96 | $1,508.43 | $2,848.13 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $86.63 / $296.75 / $535.98
| Professional | 25 | $86.63 | $296.75 | $535.98 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $173.81 / $364.14 / $687.55
| Professional | 25 | $173.81 | $364.14 | $687.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.43 / $3,683.00 / $4,185.00
| Facility | | $202.43 | $3,683.00 | $4,185.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,116.00 / $3,303.00 / $3,952.00
| Facility | | $2,116.00 | $3,303.00 | $3,952.00 |