- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $527.87 / $527.87 / $1,121.72
| Facility | | $527.87 | $527.87 | $1,121.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.87 / $527.87 / $527.87
| Professional | | $527.87 | $527.87 | $527.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.15 / $211.15 / $343.11
| Professional | | $211.15 | $211.15 | $343.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.87 / $632.44 / $936.92
| Professional | | $527.87 | $632.44 | $936.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $527.87 / $527.87 / $855.15
| Facility | | $527.87 | $527.87 | $855.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.87 / $527.87 / $527.87
| Professional | | $527.87 | $527.87 | $527.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.72 / $316.72 / $923.77
| Professional | | $316.72 | $316.72 | $923.77 |