- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.29 / $99.43 / $104.40
| Facility | | $95.29 | $99.43 | $104.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.90 / $86.00 / $99.43
| Professional | | $81.90 | $86.00 | $99.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.90 / $89.90 / $89.90
| Facility | | $89.90 | $89.90 | $89.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.83 / $89.90 / $89.90
| Professional | | $81.83 | $89.90 | $89.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.72 / $79.34 / $81.90
| Facility | | $68.72 | $79.34 | $81.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.90 / $81.90 / $88.85
| Professional | | $81.90 | $81.90 | $88.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.90 / $86.00 / $98.61
| Professional | | $81.90 | $86.00 | $98.61 |