- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.95 / $197.92 / $197.92
| Facility | | $169.95 | $197.92 | $197.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.72 / $139.05 / $180.00
| Professional | | $105.72 | $139.05 | $180.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.77 / $141.03 / $166.91
| Professional | | $105.77 | $141.03 | $166.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.84 / $146.36 / $175.35
| Professional | | $106.84 | $146.36 | $175.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $128.75 / $213.67
| Professional | | $75.00 | $128.75 | $213.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.17 / $140.59 / $183.60
| Professional | | $106.17 | $140.59 | $183.60 |