- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.35 / $1,023.69 / $8,500.00
| Facility | | $146.35 | $1,023.69 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.35 / $860.35 / $1,103.00
| Professional | | $146.35 | $860.35 | $1,103.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.23 / $1,321.96 / $2,278.90
| Professional | | $295.23 | $1,321.96 | $2,278.90 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $442.85 / $573.12 / $3,270.47
| Professional | 50 | $442.85 | $573.12 | $3,270.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.88 / $1,164.35 / $2,871.37
| Professional | | $215.88 | $1,164.35 | $2,871.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.35 / $1,023.69 / $1,740.27
| Facility | | $146.35 | $1,023.69 | $1,740.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.90 / $1,954.40 / $2,693.71
| Professional | | $1,144.90 | $1,954.40 | $2,693.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.14 / $1,873.48 / $2,693.71
| Professional | | $256.14 | $1,873.48 | $2,693.71 |