- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.58 / $319.58 / $368.75
| Professional | | $319.58 | $319.58 | $368.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $434.07 / $434.07 / $434.07
| Facility | | $434.07 | $434.07 | $434.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.87 / $316.87 / $462.74
| Professional | | $316.87 | $316.87 | $462.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $434.07 / $434.07 / $434.07
| Facility | | $434.07 | $434.07 | $434.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.87 / $434.07 / $462.74
| Professional | | $316.87 | $434.07 | $462.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.82 / $450.57 / $757.09
| Professional | | $217.82 | $450.57 | $757.09 |