- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.10 / $242.10 / $242.10
| Facility | | $242.10 | $242.10 | $242.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.12 / $242.10 / $242.10
| Professional | | $207.12 | $242.10 | $242.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.98 / $664.63 / $964.27
| Facility | | $482.98 | $664.63 | $964.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.20 / $106.20 / $106.20
| Professional | | $106.20 | $106.20 | $106.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.10 / $242.10 / $278.42
| Facility | | $242.10 | $242.10 | $278.42 |