- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.74 / $496.74 / $853.00
| Professional | | $496.74 | $496.74 | $853.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.35 / $562.35 / $562.35
| Facility | | $562.35 | $562.35 | $562.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $468.62 / $562.28 / $937.14
| Facility | | $468.62 | $562.28 | $937.14 |
- 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 / $562.28 / $937.14
| Facility | | $468.62 | $562.28 | $937.14 |
- 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
- $471.90 / $556.35 / $586.15
| Professional | | $471.90 | $556.35 | $586.15 |