- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.11 / $1,709.82 / $8,500.00
| Facility | | $151.11 | $1,709.82 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.43 / $854.17 / $2,060.27
| Professional | | $142.43 | $854.17 | $2,060.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.92 / $380.38 / $2,969.69
| Professional | | $293.92 | $380.38 | $2,969.69 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $440.88 / $570.57 / $4,454.54
| Professional | 50 | $440.88 | $570.57 | $4,454.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.77 / $429.33 / $3,472.11
| Professional | | $203.77 | $429.33 | $3,472.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.11 / $1,709.82 / $2,906.69
| Facility | | $151.11 | $1,709.82 | $2,906.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.67 / $3,158.45 / $4,500.42
| Professional | | $1,719.67 | $3,158.45 | $4,500.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,978.00 / $1,978.00 / $1,978.00
| Facility | | $1,978.00 | $1,978.00 | $1,978.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.67 / $3,158.45 / $4,500.42
| Professional | | $1,719.67 | $3,158.45 | $4,500.42 |