- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.80 / $123.80 / $123.80
| Professional | | $123.80 | $123.80 | $123.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.79 / $145.38 / $242.32
| Facility | | $116.79 | $145.38 | $242.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.80 / $123.80 / $242.32
| Professional | | $123.80 | $123.80 | $242.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.79 / $145.38 / $242.32
| Facility | | $116.79 | $145.38 | $242.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.80 / $123.80 / $242.32
| Professional | | $123.80 | $123.80 | $242.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.80 / $123.80 / $371.40
| Professional | | $123.80 | $123.80 | $371.40 |