- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.93 / $256.37 / $3,836.03
| Professional | | $230.93 | $256.37 | $3,836.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.00 / $675.00 / $8,194.00
| Professional | | $462.00 | $675.00 | $8,194.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $693.00 / $1,215.00 / $12,291.00
| Professional | 50 | $693.00 | $1,215.00 | $12,291.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.22 / $594.48 / $8,872.12
| Professional | | $347.22 | $594.48 | $8,872.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,041.20 / $9,116.71 / $14,498.88
| Professional | | $6,041.20 | $9,116.71 | $14,498.88 |