- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.70 / $205.70 / $205.70
| Facility | | $205.70 | $205.70 | $205.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.02 / $205.70 / $205.70
| Professional | | $196.02 | $205.70 | $205.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.70 / $205.70 / $205.70
| Facility | | $205.70 | $205.70 | $205.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.70 / $205.70 / $205.70
| Professional | | $205.70 | $205.70 | $205.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.00 / $220.00 / $220.00
| Professional | | $198.00 | $220.00 | $220.00 |