- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,688.05 / $2,688.05 / $26,500.30
| Professional | | $2,688.05 | $2,688.05 | $26,500.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.86 / $4,260.10 / $6,698.24
| Professional | | $944.86 | $4,260.10 | $6,698.24 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,417.29 / $1,834.23 / $10,047.36
| Professional | 50 | $1,417.29 | $1,834.23 | $10,047.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.66 / $4,383.74 / $7,334.33
| Professional | | $649.66 | $4,383.74 | $7,334.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $480.67 / $3,973.42 / $6,754.81
| Facility | | $480.67 | $3,973.42 | $6,754.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,485.04 / $8,575.83 / $10,444.60
| Professional | | $4,485.04 | $8,575.83 | $10,444.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,042.13 / $8,545.79 / $10,444.60
| Professional | | $5,042.13 | $8,545.79 | $10,444.60 |