- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,028.45 / $8,028.45 / $8,028.45
| Facility | | $8,028.45 | $8,028.45 | $8,028.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.10 / $223.03 / $324.95
| Professional | | $192.10 | $223.03 | $324.95 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $202.01 / $315.05 / $1,246.94
| Professional | 25 | $202.01 | $315.05 | $1,246.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.00 / $378.00 / $490.00
| Professional | | $378.00 | $378.00 | $490.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.64 / $365.23 / $576.07
| Professional | | $214.64 | $365.23 | $576.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.38 / $500.07 / $805.10
| Professional | | $331.38 | $500.07 | $805.10 |