- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.77 / $137.77 / $162.08
| Professional | | $137.77 | $137.77 | $162.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Professional | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Facility | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Professional | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Professional | | $162.08 | $162.08 | $162.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.77 / $137.77 / $137.77
| Professional | | $137.77 | $137.77 | $137.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.48 / $162.08 / $235.02
| Professional | | $31.48 | $162.08 | $235.02 |