- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $258.06
| Professional | | $138.74 | $138.74 | $258.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.88 / $154.38 / $257.29
| Facility | | $130.88 | $154.38 | $257.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $257.29
| Professional | | $138.74 | $138.74 | $257.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.88 / $154.38 / $257.29
| Facility | | $130.88 | $154.38 | $257.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $257.29
| Professional | | $138.74 | $138.74 | $257.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $138.74 / $416.22
| Professional | | $138.74 | $138.74 | $416.22 |