- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.16 / $278.10 / $2,300.66
| Facility | | $151.16 | $278.10 | $2,300.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $190.47
| Professional | | $151.16 | $151.16 | $190.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $152.31 / $176.35 / $291.74
| Facility | | $152.31 | $176.35 | $291.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $182.84
| Professional | | $151.16 | $151.16 | $182.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.88 / $151.16 / $151.16
| Facility | | $146.88 | $151.16 | $151.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $171.13
| Professional | | $151.16 | $151.16 | $171.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $172.33
| Professional | | $151.16 | $151.16 | $172.33 |