- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.72 / $8,561.59 / $8,561.59
| Professional | | $2,039.72 | $8,561.59 | $8,561.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.00 / $416.00 / $4,358.00
| Professional | | $285.00 | $416.00 | $4,358.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $427.50 / $748.50 / $6,537.00
| Professional | 50 | $427.50 | $748.50 | $6,537.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.11 / $380.29 / $4,629.33
| Professional | | $228.11 | $380.29 | $4,629.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,834.15 / $4,154.32 / $8,383.33
| Professional | | $2,834.15 | $4,154.32 | $8,383.33 |