- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.31 / $340.31 / $583.71
| Professional | | $340.31 | $340.31 | $583.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.26 / $385.26 / $385.26
| Facility | | $385.26 | $385.26 | $385.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $321.05 / $340.31 / $641.58
| Facility | | $321.05 | $340.31 | $641.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.31 / $340.31 / $340.31
| Professional | | $340.31 | $340.31 | $340.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $321.05 / $340.31 / $641.58
| Facility | | $321.05 | $340.31 | $641.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.31 / $340.31 / $340.31
| Professional | | $340.31 | $340.31 | $340.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.29 / $340.31 / $353.92
| Professional | | $323.29 | $340.31 | $353.92 |