- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.74 / $595.94 / $1,090.23
| Facility | | $496.74 | $595.94 | $1,090.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.74 / $501.59 / $600.78
| Professional | | $496.74 | $501.59 | $600.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.74 / $799.75 / $1,488.98
| Facility | | $496.74 | $799.75 | $1,488.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.74 / $496.74 / $496.74
| Professional | | $496.74 | $496.74 | $496.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $468.62 / $496.74 / $496.74
| Facility | | $468.62 | $496.74 | $496.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.74 / $496.74 / $496.74
| Professional | | $496.74 | $496.74 | $496.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.74 / $496.74 / $556.35
| Professional | | $496.74 | $496.74 | $556.35 |