- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $527.08
| Professional | | $308.68 | $308.68 | $527.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $349.45 / $349.45 / $349.45
| Facility | | $349.45 | $349.45 | $349.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.20 / $332.76 / $554.59
| Facility | | $291.20 | $332.76 | $554.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $308.68
| Professional | | $308.68 | $308.68 | $308.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.20 / $332.76 / $554.59
| Facility | | $291.20 | $332.76 | $554.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $308.68
| Professional | | $308.68 | $308.68 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.25 / $308.68 / $321.02
| Professional | | $293.25 | $308.68 | $321.02 |