- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $602.56 / $954.99
| Facility | | $354.81 | $602.56 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $70.79
| Professional | | $64.57 | $64.57 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $87.10 / $87.10
| Professional | | $64.57 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.54 / $27.54 / $27.54
| Professional | | $27.54 | $27.54 | $27.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $602.56 / $954.99
| Facility | | $354.81 | $602.56 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $77.62
| Professional | | $64.57 | $64.57 | $77.62 |