- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.74 / $146.74 / $146.74
| Facility | | $146.74 | $146.74 | $146.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.74 / $146.74 / $508.74
| Professional | | $146.74 | $146.74 | $508.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.58 / $482.58 / $482.58
| Professional | | $482.58 | $482.58 | $482.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.96 / $508.74 / $1,393.95
| Facility | | $246.96 | $508.74 | $1,393.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.58 / $482.58 / $482.58
| Facility | | $482.58 | $482.58 | $482.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.23 / $482.58 / $496.01
| Professional | | $438.23 | $482.58 | $496.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.17 / $84.17 / $84.17
| Professional | | $84.17 | $84.17 | $84.17 |