- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $490.08 / $490.08 / $1,891.71
| Facility | | $490.08 | $490.08 | $1,891.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.08 / $490.08 / $490.08
| Professional | | $490.08 | $490.08 | $490.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $570.67 / $896.34 / $1,633.60
| Facility | | $570.67 | $896.34 | $1,633.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Professional | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Facility | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.71 / $520.71 / $520.71
| Professional | | $520.71 | $520.71 | $520.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $490.08 / $490.08 / $727.10
| Facility | | $490.08 | $490.08 | $727.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.00 / $921.00 / $921.00
| Professional | | $921.00 | $921.00 | $921.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.50 / $510.50 / $510.50
| Professional | | $510.50 | $510.50 | $510.50 |