- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.59 / $206.59 / $206.62
| Facility | | $206.59 | $206.59 | $206.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.59 / $206.59 / $355.38
| Professional | | $206.59 | $206.59 | $355.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33,038.96 / $40,094.32 / $53,939.70
| Facility | | $33,038.96 | $40,094.32 | $53,939.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.26 / $206.59 / $206.59
| Professional | | $200.26 | $206.59 | $206.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.59 / $206.59 / $206.59
| Facility | | $206.59 | $206.59 | $206.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.59 / $206.59 / $297.83
| Professional | | $206.59 | $206.59 | $297.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.59 / $206.59 / $206.59
| Professional | | $206.59 | $206.59 | $206.59 |