- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.62 / $461.62 / $461.62
| Professional | | $461.62 | $461.62 | $461.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.50 / $0.50 / $0.50
| Facility | | $0.50 | $0.50 | $0.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.50 / $0.50 / $0.50
| Professional | | $0.50 | $0.50 | $0.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $506.88 / $506.88 / $506.88
| Facility | | $506.88 | $506.88 | $506.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.88 / $506.88 / $506.88
| Professional | | $506.88 | $506.88 | $506.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.61 / $452.57 / $543.08
| Professional | | $159.61 | $452.57 | $543.08 |