- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.74 / $270.51 / $713.77
| Facility | | $260.74 | $270.51 | $713.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.74 / $270.51 / $277.02
| Professional | | $260.74 | $270.51 | $277.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.97 / $277.02 / $277.02
| Facility | | $268.97 | $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
- 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 / $287.89
| Professional | | $271.60 | $271.60 | $287.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.70 / $263.70 / $263.70
| Professional | | $263.70 | $263.70 | $263.70 |