- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.76 / $841.31 / $3,140.00
| Facility | | $144.76 | $841.31 | $3,140.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.53 / $165.48 / $367.75
| Professional | | $44.53 | $165.48 | $367.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.51 / $175.33 / $452.81
| Professional | | $47.51 | $175.33 | $452.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,081.81 / $2,081.81 / $2,081.81
| Facility | | $2,081.81 | $2,081.81 | $2,081.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.23 / $245.23 / $245.23
| Professional | | $245.23 | $245.23 | $245.23 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $372.51 / $372.51 / $372.51
| Professional | 50 | $372.51 | $372.51 | $372.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.92 / $357.16 / $683.08
| Professional | | $263.92 | $357.16 | $683.08 |