- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.25 / $1,925.36 / $8,500.00
| Facility | | $156.25 | $1,925.36 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.25 / $911.89 / $2,243.69
| Professional | | $156.25 | $911.89 | $2,243.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.67 / $2,314.79 / $3,990.40
| Professional | | $311.67 | $2,314.79 | $3,990.40 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $467.51 / $605.03 / $5,726.67
| Professional | 50 | $467.51 | $605.03 | $5,726.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.90 / $2,057.76 / $5,050.74
| Professional | | $228.90 | $2,057.76 | $5,050.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.25 / $1,925.36 / $3,273.11
| Facility | | $156.25 | $1,925.36 | $3,273.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,255.48 / $3,850.21 / $5,071.35
| Professional | | $2,255.48 | $3,850.21 | $5,071.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,932.24 / $4,019.06 / $5,071.35
| Professional | | $1,932.24 | $4,019.06 | $5,071.35 |