- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $92.98 / $92.98 / $151.49
| Facility | | $92.98 | $92.98 | $151.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.41 / $92.98 / $96.83
| Professional | | $89.41 | $92.98 | $96.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.41 / $89.41 / $89.41
| Professional | | $89.41 | $89.41 | $89.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.41 / $89.41 / $89.41
| Facility | | $89.41 | $89.41 | $89.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.41 / $89.41 / $89.41
| Professional | | $89.41 | $89.41 | $89.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.79 / $92.79 / $111.85
| Professional | | $92.79 | $92.79 | $111.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.94 / $89.41 / $93.88
| Professional | | $84.94 | $89.41 | $93.88 |