- 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
- $130.12 / $145.00 / $241.66
| Facility | | $130.12 | $145.00 | $241.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $241.66
| Professional | | $137.93 | $137.93 | $241.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.12 / $145.00 / $241.66
| Facility | | $130.12 | $145.00 | $241.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $241.66
| Professional | | $137.93 | $137.93 | $241.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.93 / $137.93 / $413.79
| Professional | | $137.93 | $137.93 | $413.79 |