- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.72 / $2,080.00 / $4,100.00
| Facility | | $245.72 | $2,080.00 | $4,100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.75 / $245.72 / $245.72
| Professional | | $151.75 | $245.72 | $245.72 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $633.37 / $633.37 / $633.37
| Professional | 50 | $633.37 | $633.37 | $633.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.30 / $150.04 / $1,410.00
| Professional | | $126.30 | $150.04 | $1,410.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.63 / $242.85 / $504.16
| Professional | | $146.63 | $242.85 | $504.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.43 / $513.09 / $513.09
| Professional | | $241.43 | $513.09 | $513.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.00 / $442.00 / $5,940.00
| Facility | | $165.00 | $442.00 | $5,940.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.48 / $504.78 / $598.23
| Professional | | $202.48 | $504.78 | $598.23 |