- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.10 / $344.10 / $397.04
| Professional | | $344.10 | $344.10 | $397.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.50 / $437.50 / $437.50
| Facility | | $437.50 | $437.50 | $437.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.38 / $437.50 / $450.63
| Professional | | $319.38 | $437.50 | $450.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $437.50 / $437.50 / $437.50
| Facility | | $437.50 | $437.50 | $437.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.38 / $437.50 / $450.63
| Professional | | $319.38 | $437.50 | $450.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.96 / $449.98 / $814.37
| Professional | | $224.96 | $449.98 | $814.37 |