- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $594.75
| Professional | | $346.11 | $346.11 | $594.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.82 / $391.82 / $391.82
| Facility | | $391.82 | $391.82 | $391.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.52 / $384.89 / $641.49
| Facility | | $326.52 | $384.89 | $641.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $346.11
| Professional | | $346.11 | $346.11 | $346.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.52 / $384.89 / $641.49
| Facility | | $326.52 | $384.89 | $641.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $346.11
| Professional | | $346.11 | $346.11 | $346.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.80 / $346.11 / $532.41
| Professional | | $328.80 | $346.11 | $532.41 |