- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $7,413.10 / $9,772.37
| Facility | | $2,089.30 | $7,413.10 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $229.09 / $602.56
| Professional | | $173.78 | $229.09 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $194.98 / $309.03 / $851.14
| Professional | 25 | $194.98 | $309.03 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $380.19 / $489.78
| Professional | | $380.19 | $380.19 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $346.74 / $588.84
| Professional | | $208.93 | $346.74 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $398.11 / $776.25
| Professional | | $251.19 | $398.11 | $776.25 |