- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.48 / $306.48 / $488.46
| Facility | | $306.48 | $306.48 | $488.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.70 / $349.58 / $488.46
| Professional | | $287.70 | $349.58 | $488.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $520.54 / $520.54 / $520.54
| Facility | | $520.54 | $520.54 | $520.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.54 / $520.54 / $520.54
| Professional | | $520.54 | $520.54 | $520.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $361.45 / $361.45 / $361.45
| Facility | | $361.45 | $361.45 | $361.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.86 / $263.86 / $361.45
| Professional | | $263.86 | $263.86 | $361.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.66 / $256.82 / $407.27
| Professional | | $169.66 | $256.82 | $407.27 |