- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $222.62
| Professional | | $129.47 | $129.47 | $222.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.58 / $146.58 / $146.58
| Facility | | $146.58 | $146.58 | $146.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.15 / $146.61 / $244.34
| Facility | | $122.15 | $146.61 | $244.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $129.47
| Professional | | $129.47 | $129.47 | $129.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $122.15 / $146.61 / $244.34
| Facility | | $122.15 | $146.61 | $244.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $129.47 / $129.47
| Professional | | $129.47 | $129.47 | $129.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.01 / $129.47 / $137.25
| Professional | | $123.01 | $129.47 | $137.25 |