- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.50 / $297.33 / $297.33
| Facility | | $280.50 | $297.33 | $297.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.50 / $297.33 / $297.33
| Professional | | $280.50 | $297.33 | $297.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $313.50 / $313.50 / $470.25
| Facility | | $313.50 | $313.50 | $470.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.50 / $313.50 / $319.77
| Professional | | $313.50 | $313.50 | $319.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.48 / $326.48 / $326.48
| Facility | | $326.48 | $326.48 | $326.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.48 / $326.48 / $326.48
| Professional | | $326.48 | $326.48 | $326.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.25 / $339.28 / $360.30
| Professional | | $283.25 | $339.28 | $360.30 |