- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.15 / $575.73 / $8,500.00
| Facility | | $101.15 | $575.73 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.24 / $483.80 / $616.26
| Professional | | $94.24 | $483.80 | $616.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.31 / $840.80 / $1,449.44
| Professional | | $193.31 | $840.80 | $1,449.44 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $289.97 / $375.27 / $2,080.11
| Professional | 50 | $289.97 | $375.27 | $2,080.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.75 / $539.35 / $1,829.15
| Professional | | $142.75 | $539.35 | $1,829.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.15 / $565.90 / $1,547.23
| Facility | | $101.15 | $565.90 | $1,547.23 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $2,416.23 / $2,416.23 / $3,094.46
| Facility | 50 | $2,416.23 | $2,416.23 | $3,094.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.38 / $955.90 / $1,514.81
| Professional | | $534.38 | $955.90 | $1,514.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.38 / $1,056.18 / $1,514.81
| Professional | | $534.38 | $1,056.18 | $1,514.81 |