- 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
- $193.60 / $200.86 / $205.70
| Professional | | $193.60 | $200.86 | $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 / $226.60
| Professional | | $198.00 | $220.00 | $226.60 |