- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $529.89 / $1,501.88 / $2,023.80
| Facility | | $529.89 | $1,501.88 | $2,023.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.89 / $529.89 / $529.89
| Professional | | $529.89 | $529.89 | $529.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.89 / $820.55 / $1,387.47
| Professional | | $529.89 | $820.55 | $1,387.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $499.90 / $499.90 / $529.89
| Facility | | $499.90 | $499.90 | $529.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.41 / $450.41 / $529.89
| Professional | | $450.41 | $450.41 | $529.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.89 / $529.89 / $858.84
| Professional | | $529.89 | $529.89 | $858.84 |