- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.50 / $250.98 / $273.35
| Facility | | $248.50 | $250.98 | $273.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.50 / $248.50 / $260.92
| Professional | | $248.50 | $248.50 | $260.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $248.50 / $273.35 / $372.75
| Facility | | $248.50 | $273.35 | $372.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.50 / $248.50 / $576.16
| Professional | | $248.50 | $248.50 | $576.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.43 / $243.63 / $248.50
| Facility | | $234.43 | $243.63 | $248.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.50 / $248.50 / $257.87
| Professional | | $248.50 | $248.50 | $257.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.50 / $273.35 / $286.94
| Professional | | $248.50 | $273.35 | $286.94 |