- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $143.44 / $143.44
| Professional | | $137.93 | $143.44 | $143.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Professional | | $137.93 | $137.93 | $137.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Facility | | $137.93 | $137.93 | $137.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Professional | | $137.93 | $137.93 | $137.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $137.93
| Professional | | $137.93 | $137.93 | $137.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $143.44 / $143.44
| Professional | | $137.93 | $143.44 | $143.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $200.00
| Professional | | $137.93 | $137.93 | $200.00 |