- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.60 / $137.93 / $190.05
| Facility | | $108.60 | $137.93 | $190.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $144.82
| Professional | | $137.93 | $137.93 | $144.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Facility | | $137.93 | $137.93 | $137.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Professional | | $137.93 | $137.93 | $137.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.37 / $329.31 / $1,027.45
| Facility | | $170.37 | $329.31 | $1,027.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.45 / $1,027.45 / $1,027.45
| Professional | | $1,027.45 | $1,027.45 | $1,027.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.03 / $137.93 / $137.93
| Professional | | $131.03 | $137.93 | $137.93 |