- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $324.12 / $368.15 / $370.42
| Facility | | $324.12 | $368.15 | $370.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $324.12 / $416.72
| Professional | | $308.68 | $324.12 | $416.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.06 / $205.06 / $225.57
| Facility | | $205.06 | $205.06 | $225.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.66 / $308.68 / $308.68
| Facility | | $239.66 | $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
- $291.82 / $308.68 / $401.28
| Professional | | $291.82 | $308.68 | $401.28 |