- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.50 / $247.50 / $247.50
| Professional | | $247.50 | $247.50 | $247.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.25 / $1,031.25 / $1,031.25
| Professional | | $1,031.25 | $1,031.25 | $1,031.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.00 / $260.00 / $260.00
| Facility | | $260.00 | $260.00 | $260.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.93 / $205.93 / $205.93
| Professional | | $205.93 | $205.93 | $205.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.00 / $260.00 / $260.00
| Facility | | $260.00 | $260.00 | $260.00 |