- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.27 / $151.27 / $181.52
| Facility | | $151.27 | $151.27 | $181.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.16 / $151.27 / $151.27
| Professional | | $144.16 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.05 / $77.05 / $77.05
| Professional | | $77.05 | $77.05 | $77.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.27 / $151.27 / $151.27
| Facility | | $151.27 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.27 / $151.27 / $151.27
| Professional | | $151.27 | $151.27 | $151.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.79 / $161.79 / $161.79
| Professional | | $161.79 | $161.79 | $161.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |