- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.37 / $1,910.76 / $8,500.00
| Facility | | $142.37 | $1,910.76 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.37 / $831.76 / $3,799.61
| Professional | | $142.37 | $831.76 | $3,799.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.05 / $2,293.64 / $3,953.93
| Professional | | $284.05 | $2,293.64 | $3,953.93 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $426.08 / $551.41 / $5,674.32
| Professional | 50 | $426.08 | $551.41 | $5,674.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.95 / $2,040.45 / $5,007.49
| Professional | | $223.95 | $2,040.45 | $5,007.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.37 / $1,910.76 / $4,857.10
| Facility | | $142.37 | $1,910.76 | $4,857.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,464.60 / $4,107.66 / $5,033.51
| Professional | | $2,464.60 | $4,107.66 | $5,033.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,259.21 / $3,987.53 / $5,033.51
| Professional | | $2,259.21 | $3,987.53 | $5,033.51 |