- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.98 / $526.98 / $526.98
| Professional | | $526.98 | $526.98 | $526.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,745.55 / $1,745.55 / $1,878.62
| Facility | | $1,745.55 | $1,745.55 | $1,878.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.98 / $526.98 / $526.98
| Professional | | $526.98 | $526.98 | $526.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $526.98 / $526.98 / $526.98
| Professional | | $526.98 | $526.98 | $526.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.65 / $526.98 / $1,193.67
| Professional | | $516.65 | $526.98 | $1,193.67 |