- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $431.50
| Professional | | $134.88 | $134.88 | $431.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.25 / $154.50 / $257.50
| Facility | | $127.25 | $154.50 | $257.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $257.50
| Professional | | $134.88 | $134.88 | $257.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.25 / $154.50 / $257.50
| Facility | | $127.25 | $154.50 | $257.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $257.50
| Professional | | $134.88 | $134.88 | $257.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.88 / $134.88 / $404.67
| Professional | | $134.88 | $134.88 | $404.67 |