- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.84 / $350.84 / $404.82
| Professional | | $350.84 | $350.84 | $404.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $484.42 / $484.42 / $528.41
| Facility | | $484.42 | $484.42 | $528.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.63 / $484.42 / $516.41
| Professional | | $353.63 | $484.42 | $516.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $484.42 / $484.42 / $528.41
| Facility | | $484.42 | $484.42 | $528.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.63 / $484.42 / $516.41
| Professional | | $353.63 | $484.42 | $516.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.12 / $444.80 / $831.15
| Professional | | $239.12 | $444.80 | $831.15 |