- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.98 / $87.98 / $89.74
| Facility | | $87.98 | $87.98 | $89.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.98 / $87.98 / $95.02
| Professional | | $87.98 | $87.98 | $95.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.98 / $93.39 / $158.01
| Facility | | $87.98 | $93.39 | $158.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.98 / $87.98 / $121.42
| Professional | | $87.98 | $87.98 | $121.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.49 / $87.98 / $87.98
| Facility | | $85.49 | $87.98 | $87.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.98 / $87.98 / $87.98
| Professional | | $87.98 | $87.98 | $87.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.98 / $87.98 / $95.02
| Professional | | $87.98 | $87.98 | $95.02 |