- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.13 / $208.19 / $226.74
| Facility | | $206.13 | $208.19 | $226.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $217.48
| Professional | | $207.13 | $207.13 | $217.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.13 / $227.84 / $310.70
| Facility | | $207.13 | $227.84 | $310.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $480.24
| Professional | | $207.13 | $207.13 | $480.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.40 / $206.81 / $207.13
| Facility | | $195.40 | $206.81 | $207.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $214.94
| Professional | | $207.13 | $207.13 | $214.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $229.91 / $247.50
| Professional | | $207.13 | $229.91 | $247.50 |