- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.94 / $540.94 / $540.94
| Professional | | $528.94 | $540.94 | $540.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.00 / $2,843.00 / $3,412.00
| Professional | | $1,758.00 | $2,843.00 | $3,412.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $2,637.00 / $4,264.50 / $5,118.00
| Professional | 50 | $2,637.00 | $4,264.50 | $5,118.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.59 / $831.05 / $1,200.40
| Professional | | $615.59 | $831.05 | $1,200.40 |
- 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
- $608.23 / $1,324.51 / $2,376.01
| Professional | | $608.23 | $1,324.51 | $2,376.01 |