- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.02 / $349.02 / $349.02
| Professional | | $349.02 | $349.02 | $349.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.26 / $408.12 / $680.20
| Facility | | $329.26 | $408.12 | $680.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.01 / $349.01 / $680.20
| Professional | | $349.01 | $349.01 | $680.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $329.26 / $408.12 / $680.20
| Facility | | $329.26 | $408.12 | $680.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.01 / $349.01 / $680.20
| Professional | | $349.01 | $349.01 | $680.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.02 / $349.02 / $1,047.06
| Professional | | $349.02 | $349.02 | $1,047.06 |