- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.40 / $1,698.40 / $1,698.40
| Professional | | $1,698.40 | $1,698.40 | $1,698.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.00 / $2,144.00 / $2,795.00
| Professional | | $1,326.00 | $2,144.00 | $2,795.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,989.00 / $3,216.00 / $4,192.50
| Professional | 50 | $1,989.00 | $3,216.00 | $4,192.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.90 / $759.07 / $1,109.41
| Professional | | $583.90 | $759.07 | $1,109.41 |
- 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
- $622.44 / $1,148.58 / $1,879.79
| Professional | | $622.44 | $1,148.58 | $1,879.79 |