- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.68 / $369.28 / $673.66
| Facility | | $308.68 | $369.28 | $673.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $311.77 / $371.83
| Professional | | $308.68 | $311.77 | $371.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.68 / $499.75 / $951.74
| Facility | | $308.68 | $499.75 | $951.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $308.68
| Professional | | $308.68 | $308.68 | $308.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.20 / $308.68 / $308.68
| Facility | | $291.20 | $308.68 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $308.68
| Professional | | $308.68 | $308.68 | $308.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $631.97 / $631.97 / $631.97
| Facility | | $631.97 | $631.97 | $631.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.43 / $308.68 / $332.75
| Professional | | $307.43 | $308.68 | $332.75 |