- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.08 / $289.08 / $484.96
| Professional | | $289.08 | $289.08 | $484.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.78 / $340.78 / $340.78
| Facility | | $340.78 | $340.78 | $340.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.08 / $289.08 / $289.08
| Professional | | $289.08 | $289.08 | $289.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.78 / $340.78 / $340.78
| Facility | | $340.78 | $340.78 | $340.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.08 / $289.08 / $289.08
| Professional | | $289.08 | $289.08 | $289.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.03 / $283.42 / $330.06
| Professional | | $191.03 | $283.42 | $330.06 |