- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $410.09 / $430.60 / $471.60
| Facility | | $410.09 | $430.60 | $471.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.27 / $430.60 / $440.98
| Professional | | $395.27 | $430.60 | $440.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $419.98 / $440.98 / $440.98
| Facility | | $419.98 | $440.98 | $440.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.98 / $440.98 / $440.98
| Professional | | $440.98 | $440.98 | $440.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.74 / $411.74 / $411.74
| Professional | | $411.74 | $411.74 | $411.74 |