- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.52 / $377.52 / $646.79
| Professional | | $377.52 | $377.52 | $646.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $427.38 / $427.38 / $427.38
| Facility | | $427.38 | $427.38 | $427.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $356.15 / $419.38 / $698.97
| Facility | | $356.15 | $419.38 | $698.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.52 / $377.52 / $377.52
| Professional | | $377.52 | $377.52 | $377.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $356.15 / $419.38 / $698.97
| Facility | | $356.15 | $419.38 | $698.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.52 / $377.52 / $377.52
| Professional | | $377.52 | $377.52 | $377.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.61 / $377.52 / $420.26
| Professional | | $372.61 | $377.52 | $420.26 |