- Facility/Professional
- Facility
- Modifier
- 25
- Low / Median / High Price
- $4,012.99 / $4,012.99 / $4,012.99
| Facility | 25 | $4,012.99 | $4,012.99 | $4,012.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.09 / $241.13 / $721.63
| Professional | | $192.09 | $241.13 | $721.63 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $211.58 / $296.57 / $941.72
| Professional | 25 | $211.58 | $296.57 | $941.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.98 / $450.26 / $505.12
| Professional | | $362.98 | $450.26 | $505.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.42 / $326.33 / $623.16
| Professional | | $215.42 | $326.33 | $623.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.05 / $337.07 / $623.16
| Professional | | $233.05 | $337.07 | $623.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.75 / $382.44 / $806.01
| Professional | | $284.75 | $382.44 | $806.01 |