- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $319.61 / $319.61 / $319.61
| Facility | | $319.61 | $319.61 | $319.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.50 / $319.61 / $477.48
| Professional | | $289.50 | $319.61 | $477.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.89 / $534.89 / $581.62
| Professional | | $534.89 | $534.89 | $581.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $319.61 / $319.61 / $319.61
| Facility | | $319.61 | $319.61 | $319.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.16 / $319.61 / $381.99
| Professional | | $312.16 | $319.61 | $381.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |