- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.35 / $276.27 / $8,500.00
| Facility | | $146.35 | $276.27 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.35 / $246.96 / $309.87
| Professional | | $146.35 | $246.96 | $309.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.92 / $380.38 / $713.97
| Professional | | $293.92 | $380.38 | $713.97 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $440.88 / $570.57 / $1,041.86
| Professional | 50 | $440.88 | $570.57 | $1,041.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.38 / $426.72 / $892.42
| Professional | | $215.38 | $426.72 | $892.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.35 / $276.27 / $469.66
| Facility | | $146.35 | $276.27 | $469.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.01 / $506.82 / $722.03
| Professional | | $291.01 | $506.82 | $722.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,345.72 / $3,345.72 / $3,345.72
| Facility | | $3,345.72 | $3,345.72 | $3,345.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.01 / $529.10 / $722.03
| Professional | | $291.01 | $529.10 | $722.03 |