- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,435.69 / $2,768.38 / $3,829.40
| Facility | | $2,435.69 | $2,768.38 | $3,829.40 |
- Facility/Professional
- Facility
- Modifier
- 25
- Low / Median / High Price
- $3,193.20 / $3,193.20 / $4,182.46
| Facility | 25 | $3,193.20 | $3,193.20 | $4,182.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.37 / $258.56 / $914.90
| Professional | | $187.37 | $258.56 | $914.90 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $200.00 / $381.27 / $1,208.40
| Professional | 25 | $200.00 | $381.27 | $1,208.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.30 / $265.08 / $343.16
| Professional | | $204.30 | $265.08 | $343.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.43 / $324.06 / $642.20
| Professional | | $211.43 | $324.06 | $642.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.56 / $345.67 / $514.13
| Professional | | $257.56 | $345.67 | $514.13 |