- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.37 / $3,673.59 / $8,500.00
| Facility | | $253.37 | $3,673.59 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.93 / $1,471.64 / $4,219.64
| Professional | | $230.93 | $1,471.64 | $4,219.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.35 / $4,345.71 / $7,491.44
| Professional | | $502.35 | $4,345.71 | $7,491.44 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $753.53 / $975.20 / $10,751.04
| Professional | 50 | $753.53 | $975.20 | $10,751.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.64 / $4,537.58 / $9,489.66
| Professional | | $410.64 | $4,537.58 | $9,489.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.37 / $3,673.59 / $6,245.10
| Facility | | $253.37 | $3,673.59 | $6,245.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,324.77 / $7,382.58 / $9,677.96
| Professional | | $4,324.77 | $7,382.58 | $9,677.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,430.53 / $13,430.53 / $13,430.53
| Facility | | $13,430.53 | $13,430.53 | $13,430.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,324.77 / $7,665.03 / $9,677.96
| Professional | | $4,324.77 | $7,665.03 | $9,677.96 |