- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $1,226.23
| Facility | | $151.16 | $151.16 | $1,226.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $167.94
| Professional | | $151.16 | $151.16 | $167.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $151.16
| Professional | | $151.16 | $151.16 | $151.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $151.16
| Facility | | $151.16 | $151.16 | $151.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.16 / $151.16 / $151.16
| Professional | | $151.16 | $151.16 | $151.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.52 / $151.16 / $151.16
| Professional | | $131.52 | $151.16 | $151.16 |