- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.69 / $79.69 / $98.06
| Facility | | $79.69 | $79.69 | $98.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.69 / $79.69 / $79.69
| Professional | | $79.69 | $79.69 | $79.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.50 / $79.50 / $79.50
| Professional | | $79.50 | $79.50 | $79.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.50 / $79.50 / $79.50
| Facility | | $79.50 | $79.50 | $79.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.50 / $79.50 / $79.50
| Professional | | $79.50 | $79.50 | $79.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.69 / $90.69 / $90.69
| Professional | | $90.69 | $90.69 | $90.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.69 / $87.66 / $111.57
| Professional | | $79.69 | $87.66 | $111.57 |