- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.10 / $484.95 / $484.95
| Professional | | $362.10 | $484.95 | $484.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.74 / $316.74 / $316.74
| Facility | | $316.74 | $316.74 | $316.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.23 / $316.74 / $326.24
| Professional | | $269.23 | $316.74 | $326.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.74 / $316.74 / $316.74
| Facility | | $316.74 | $316.74 | $316.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.74 / $316.74 / $326.24
| Professional | | $316.74 | $316.74 | $326.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $445.63 / $478.80
| Professional | | $60.00 | $445.63 | $478.80 |