- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.01 / $1,435.44 / $8,500.00
| Facility | | $55.01 | $1,435.44 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.10 / $1,077.49 / $1,479.22
| Professional | | $56.10 | $1,077.49 | $1,479.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.47 / $110.62 / $2,848.97
| Professional | | $85.47 | $110.62 | $2,848.97 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $128.21 / $165.93 / $4,273.46
| Professional | 50 | $128.21 | $165.93 | $4,273.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.56 / $135.02 / $3,251.55
| Professional | | $64.56 | $135.02 | $3,251.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.01 / $1,090.00 / $2,617.31
| Facility | | $55.01 | $1,090.00 | $2,617.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.37 / $2,590.63 / $3,784.90
| Professional | | $1,436.37 | $2,590.63 | $3,784.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,123.00 / $1,123.00 / $1,123.00
| Facility | | $1,123.00 | $1,123.00 | $1,123.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.73 / $2,031.76 / $3,098.11
| Professional | | $1,292.73 | $2,031.76 | $3,098.11 |