- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $244.42 / $350.66 / $357.68
| Facility | | $244.42 | $350.66 | $357.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.46 / $247.40 / $357.68
| Professional | | $238.46 | $247.40 | $357.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.52 / $177.52 / $177.52
| Facility | | $177.52 | $177.52 | $177.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $241.21 / $253.36 / $253.36
| Facility | | $241.21 | $253.36 | $253.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.36 / $253.36 / $253.36
| Professional | | $253.36 | $253.36 | $253.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.97 / $248.39 / $322.91
| Professional | | $235.97 | $248.39 | $322.91 |