- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.12 / $2,996.10 / $2,996.10
| Professional | | $346.12 | $2,996.10 | $2,996.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.00 / $1,101.00 / $1,780.00
| Professional | | $650.00 | $1,101.00 | $1,780.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $975.00 / $1,651.50 / $2,670.00
| Professional | 50 | $975.00 | $1,651.50 | $2,670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.10 / $498.43 / $864.59
| Professional | | $318.10 | $498.43 | $864.59 |
- 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
- $490.28 / $768.97 / $1,419.59
| Professional | | $490.28 | $768.97 | $1,419.59 |