- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.13 / $206.13 / $207.13
| Facility | | $206.13 | $206.13 | $207.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $248.55
| Professional | | $207.13 | $207.13 | $248.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,177.85 / $6,283.58 / $8,453.43
| Facility | | $5,177.85 | $6,283.58 | $8,453.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $207.13
| Professional | | $207.13 | $207.13 | $207.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $207.13
| Facility | | $207.13 | $207.13 | $207.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $207.13
| Professional | | $207.13 | $207.13 | $207.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.06 / $207.13 / $230.58
| Professional | | $176.06 | $207.13 | $230.58 |