- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $1,778.28
| Professional | | $812.83 | $1,148.15 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $6,918.31
| Professional | 50 | $1,230.27 | $1,230.27 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Professional | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $1,621.81
| Professional | | $954.99 | $954.99 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,778.28 / $1,995.26
| Facility | | $1,584.89 | $1,778.28 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,778.28 / $1,995.26
| Professional | | $1,584.89 | $1,778.28 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,318.26 / $1,949.84
| Facility | | $954.99 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,000.00 / $1,995.26
| Professional | | $79.43 | $1,000.00 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Facility | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,621.81 / $1,949.84
| Professional | | $1,380.38 | $1,621.81 | $1,949.84 |