- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.60 / $158.54 / $8,500.00
| Facility | | $150.60 | $158.54 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.38 / $158.54 / $241.68
| Professional | | $130.38 | $158.54 | $241.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.57 / $324.04 / $379.96
| Professional | | $294.57 | $324.04 | $379.96 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $432.35 / $484.46 / $569.94
| Professional | 50 | $432.35 | $484.46 | $569.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.18 / $295.70 / $467.31
| Professional | | $138.18 | $295.70 | $467.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.60 / $225.75 / $336.74
| Facility | | $150.60 | $225.75 | $336.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.01 / $282.08 / $1,114.40
| Professional | | $146.01 | $282.08 | $1,114.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.00 / $2,545.00 / $2,545.00
| Facility | | $2,545.00 | $2,545.00 | $2,545.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.86 / $249.52 / $373.17
| Professional | | $144.86 | $249.52 | $373.17 |