- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.24 / $159.06 / $275.08
| Facility | | $126.24 | $159.06 | $275.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $152.75
| Professional | | $127.45 | $127.45 | $152.75 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $183.21 / $1,102.17 / $1,102.17
| Facility | | $183.21 | $1,102.17 | $1,102.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $183.21
| Professional | | $127.45 | $127.45 | $183.21 |