- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.50 / $127.50 / $127.50
| Facility | | $127.50 | $127.50 | $127.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.00 / $124.50 / $127.50
| Professional | | $120.00 | $124.50 | $127.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.50 / $127.50 / $127.50
| Facility | | $127.50 | $127.50 | $127.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.50 / $127.50 / $127.50
| Professional | | $127.50 | $127.50 | $127.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.00 / $150.00 / $153.00
| Professional | | $135.00 | $150.00 | $153.00 |