- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.06 / $535.72 / $2,000.00
| Facility | | $108.06 | $535.72 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.06 / $367.64 / $650.28
| Professional | | $108.06 | $367.64 | $650.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.77 / $294.80 / $1,293.45
| Professional | | $207.77 | $294.80 | $1,293.45 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $311.66 / $442.20 / $1,933.71
| Professional | 50 | $311.66 | $442.20 | $1,933.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.74 / $181.74 / $181.74
| Facility | | $181.74 | $181.74 | $181.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.88 / $370.94 / $1,353.64
| Professional | | $139.88 | $370.94 | $1,353.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.93 / $275.08 / $1,064.71
| Facility | | $135.93 | $275.08 | $1,064.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.96 / $1,219.92 / $4,525.52
| Professional | | $580.96 | $1,219.92 | $4,525.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.79 / $982.78 / $1,417.88
| Professional | | $542.79 | $982.78 | $1,417.88 |