- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.24 / $127.45 / $127.45
| Facility | | $126.24 | $127.45 | $127.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $133.83
| Professional | | $127.45 | $127.45 | $133.83 |
- 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
- $127.45 / $127.45 / $181.05
| Professional | | $127.45 | $127.45 | $181.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $127.45
| Facility | | $127.45 | $127.45 | $127.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $127.45
| Professional | | $127.45 | $127.45 | $127.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $127.45
| Professional | | $127.45 | $127.45 | $127.45 |