- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $216.88
| Professional | | $127.45 | $127.45 | $216.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.29 / $144.29 / $144.29
| Facility | | $144.29 | $144.29 | $144.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.24 / $148.82 / $248.04
| Facility | | $120.24 | $148.82 | $248.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $127.45
| Professional | | $127.45 | $127.45 | $127.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.24 / $148.82 / $248.04
| Facility | | $120.24 | $148.82 | $248.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $127.45 / $127.45
| Professional | | $127.45 | $127.45 | $127.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.45 / $132.55 / $183.21
| Professional | | $127.45 | $132.55 | $183.21 |