- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.00 / $141.60 / $141.60
| Facility | | $141.00 | $141.60 | $141.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $242.52
| Professional | | $141.60 | $141.60 | $242.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,571.97 / $12,829.58 / $17,259.89
| Facility | | $10,571.97 | $12,829.58 | $17,259.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $143.69
| Professional | | $141.60 | $141.60 | $143.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $141.60
| Facility | | $141.60 | $141.60 | $141.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $172.46
| Professional | | $141.60 | $141.60 | $172.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $141.60
| Professional | | $141.60 | $141.60 | $141.60 |