- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $140.28 / $140.28
| Professional | | $134.88 | $140.28 | $140.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $137.19
| Professional | | $134.88 | $134.88 | $137.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $134.88
| Facility | | $134.88 | $134.88 | $134.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $134.88
| Professional | | $134.88 | $134.88 | $134.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $134.88
| Professional | | $134.88 | $134.88 | $134.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $140.28 / $140.28
| Professional | | $134.88 | $140.28 | $140.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $195.59
| Professional | | $134.88 | $134.88 | $195.59 |