- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $12,882.50 / $12,882.50
| Facility | | $12,882.50 | $12,882.50 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Facility | 50 | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $741.31 / $954.99 / $1,548.82
| Professional | 50 | $741.31 | $954.99 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $512.86 / $912.01 / $1,202.26
| Professional | 50 | $512.86 | $912.01 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,882.50 / $12,882.50 / $12,882.50
| Facility | | $12,882.50 | $12,882.50 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Facility | 50 | $8,709.64 | $8,709.64 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $741.31 / $954.99 / $1,548.82
| Professional | 50 | $741.31 | $954.99 | $1,548.82 |