- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Facility | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Professional | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $134.88
| Professional | | $134.88 | $134.88 | $134.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.31 / $143.31 / $143.31
| Facility | | $143.31 | $143.31 | $143.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.86 / $140.50 / $227.72
| Professional | | $127.86 | $140.50 | $227.72 |