- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,700.00 / $2,700.00 / $3,600.00
| Professional | | $2,700.00 | $2,700.00 | $3,600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,738.00 / $2,809.00 / $3,513.00
| Professional | | $1,738.00 | $2,809.00 | $3,513.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $2,607.00 / $4,213.50 / $5,269.50
| Professional | 50 | $2,607.00 | $4,213.50 | $5,269.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.98 / $967.18 / $1,413.57
| Professional | | $743.98 | $967.18 | $1,413.57 |
- 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
- $767.87 / $1,457.13 / $2,386.81
| Professional | | $767.87 | $1,457.13 | $2,386.81 |