- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.58 / $10.58 / $69.97
| Facility | | $10.58 | $10.58 | $69.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $20.00 / $22.00
| Professional | | $10.58 | $20.00 | $22.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.00 / $723.60 / $729.00
| Professional | | $612.00 | $723.60 | $729.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.44 / $206.48 / $259.63
| Professional | | $204.44 | $206.48 | $259.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.58 / $10.58 / $17.98
| Facility | | $10.58 | $10.58 | $17.98 |