- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.76 / $285.50 / $589.92
| Facility | | $273.76 | $285.50 | $589.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.56 / $270.51 / $277.02
| Professional | | $262.56 | $270.51 | $277.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $279.93 / $455.73 / $866.40
| Facility | | $279.93 | $455.73 | $866.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.60 / $271.60 / $277.02
| Professional | | $271.60 | $271.60 | $277.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $277.02 / $277.02 / $277.02
| Facility | | $277.02 | $277.02 | $277.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.02 / $277.02 / $277.02
| Professional | | $277.02 | $277.02 | $277.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.60 / $271.60 / $319.39
| Professional | | $271.60 | $271.60 | $319.39 |