- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.68 / $460.20 / $699.50
| Facility | | $308.68 | $460.20 | $699.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.80 / $308.68 / $339.55
| Professional | | $306.80 | $308.68 | $339.55 |
- 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
- $308.68 / $308.68 / $308.68
| Facility | | $308.68 | $308.68 | $308.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $326.16 / $326.16
| Professional | | $308.68 | $326.16 | $326.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $308.68 / $327.48
| Professional | | $308.68 | $308.68 | $327.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.80 / $306.80 / $308.68
| Professional | | $306.80 | $306.80 | $308.68 |