- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.86 / $239.86 / $239.86
| Professional | | $239.86 | $239.86 | $239.86 |
- 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
- $263.38 / $263.38 / $263.38
| Facility | | $263.38 | $263.38 | $263.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.38 / $263.38 / $263.38
| Professional | | $263.38 | $263.38 | $263.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.52 / $235.16 / $282.19
| Professional | | $76.52 | $235.16 | $282.19 |