- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,230.27 / $2,344.23
| Professional | | $812.83 | $1,230.27 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | 50 | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,445.44 / $1,949.84
| Professional | | $912.01 | $1,445.44 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,380.38 / $2,137.96 / $2,951.21
| Professional | 50 | $1,380.38 | $2,137.96 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,778.28 / $2,089.30
| Professional | | $977.24 | $1,778.28 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,348.96 / $1,949.84
| Professional | | $1,096.48 | $1,348.96 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,258.93 / $2,398.83
| Professional | | $758.58 | $1,258.93 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | 50 | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,288.25 / $1,905.46
| Professional | | $933.25 | $1,288.25 | $1,905.46 |