- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.49 / $145.49 / $145.49
| Professional | | $145.49 | $145.49 | $145.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.25 / $153.88 / $229.58
| Facility | | $137.25 | $153.88 | $229.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.49 / $145.49 / $229.58
| Professional | | $145.49 | $145.49 | $229.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.25 / $153.88 / $229.58
| Facility | | $137.25 | $153.88 | $229.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.49 / $145.49 / $229.58
| Professional | | $145.49 | $145.49 | $229.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.49 / $145.49 / $436.47
| Professional | | $145.49 | $145.49 | $436.47 |