- 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
- $270.51 / $270.51 / $277.02
| Professional | | $270.51 | $270.51 | $277.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.60 / $271.60 / $271.60
| Facility | | $271.60 | $271.60 | $271.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.60 / $271.60 / $271.60
| Professional | | $271.60 | $271.60 | $271.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.52 / $277.02 / $277.02
| Facility | | $225.52 | $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 / $293.91
| Professional | | $271.60 | $271.60 | $293.91 |