- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.02 / $362.98 / $362.98
| Professional | | $349.02 | $362.98 | $362.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.02 / $349.02 / $356.55
| Professional | | $349.02 | $349.02 | $356.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $349.01 / $349.01 / $349.01
| Facility | | $349.01 | $349.01 | $349.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.01 / $349.01 / $349.01
| Professional | | $349.01 | $349.01 | $349.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.02 / $349.02 / $349.02
| Professional | | $349.02 | $349.02 | $349.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.02 / $362.98 / $362.98
| Professional | | $349.02 | $362.98 | $362.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.02 / $349.02 / $523.53
| Professional | | $349.02 | $349.02 | $523.53 |