- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $337.45 / $370.42 / $370.42
| Facility | | $337.45 | $370.42 | $370.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $368.15 / $370.42
| Professional | | $308.68 | $368.15 | $370.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $332.84 / $332.84 / $332.84
| Facility | | $332.84 | $332.84 | $332.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.02 / $332.84 / $332.84
| Professional | | $305.02 | $332.84 | $332.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $254.61 / $308.68 / $308.68
| Facility | | $254.61 | $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
- Professional
- Modifier
- Low / Median / High Price
- $307.43 / $308.68 / $308.68
| Professional | | $307.43 | $308.68 | $308.68 |