- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $447.17 / $447.17 / $447.17
| Facility | | $447.17 | $447.17 | $447.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $609.15 / $1,277.75 / $1,327.15
| Professional | | $609.15 | $1,277.75 | $1,327.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.00 / $203.00 / $647.00
| Professional | | $139.00 | $203.00 | $647.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $208.50 / $366.00 / $970.50
| Professional | 50 | $208.50 | $366.00 | $970.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.32 / $187.42 / $506.38
| Professional | | $108.32 | $187.42 | $506.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.80 / $503.57 / $799.93
| Professional | | $272.80 | $503.57 | $799.93 |