- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $205.28
| Facility | | $204.61 | $204.61 | $205.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $227.32
| Professional | | $204.61 | $204.61 | $227.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.66 / $1,813.84 / $2,440.19
| Facility | | $1,494.66 | $1,813.84 | $2,440.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $204.61
| Professional | | $204.61 | $204.61 | $204.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $204.61
| Facility | | $204.61 | $204.61 | $204.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.06 / $204.61 / $261.38
| Professional | | $200.06 | $204.61 | $261.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.84 / $204.61 / $204.61
| Professional | | $81.84 | $204.61 | $204.61 |