- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,121.34 / $2,205.08 / $2,652.00
| Professional | | $2,121.34 | $2,205.08 | $2,652.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $2,975.00 / $2,975.00 / $2,975.00
| Professional | 50 | $2,975.00 | $2,975.00 | $2,975.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.00 / $2,385.00 / $3,092.00
| Professional | | $1,475.00 | $2,385.00 | $3,092.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $2,212.50 / $3,577.50 / $4,638.00
| Professional | 50 | $2,212.50 | $3,577.50 | $4,638.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.71 / $845.92 / $1,236.33
| Professional | | $650.71 | $845.92 | $1,236.33 |
- 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
- $686.39 / $1,274.65 / $2,091.67
| Professional | | $686.39 | $1,274.65 | $2,091.67 |