- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,377.00 / $1,874.25
| Professional | | $1,377.00 | $1,377.00 | $1,874.25 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $4,505.39 / $4,505.39 / $4,505.39
| Professional | 50 | $4,505.39 | $4,505.39 | $4,505.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.00 / $346.00 / $505.00
| Professional | | $288.00 | $346.00 | $505.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $432.00 / $631.50 / $757.50
| Professional | 50 | $432.00 | $631.50 | $757.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.37 / $266.85 / $372.98
| Professional | | $213.37 | $266.85 | $372.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.34 / $400.90 / $636.24
| Professional | | $240.34 | $400.90 | $636.24 |