- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.48 / $1,056.48 / $1,056.48
| Professional | | $1,056.48 | $1,056.48 | $1,056.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,039.00 / $4,914.00 / $5,897.00
| Professional | | $3,039.00 | $4,914.00 | $5,897.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $4,558.50 / $7,371.00 / $8,845.50
| Professional | 50 | $4,558.50 | $7,371.00 | $8,845.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.85 / $1,276.90 / $1,844.41
| Professional | | $945.85 | $1,276.90 | $1,844.41 |
- 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
- $973.93 / $1,941.23 / $3,066.69
| Professional | | $973.93 | $1,941.23 | $3,066.69 |