- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.92 / $65.92 / $105.34
| Facility | | $65.92 | $65.92 | $105.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.92 / $105.34 / $209.49
| Professional | | $65.92 | $105.34 | $209.49 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $32.96 / $52.67 / $52.67
| Professional | 52 | $32.96 | $52.67 | $52.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.95 / $129.54 / $202.69
| Professional | | $82.95 | $129.54 | $202.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.07 / $162.47 / $261.35
| Professional | | $91.07 | $162.47 | $261.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.11 / $164.47 / $276.89
| Professional | | $105.11 | $164.47 | $276.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.92 / $105.34 / $209.49
| Professional | | $65.92 | $105.34 | $209.49 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $32.96 / $32.96 / $52.67
| Professional | 52 | $32.96 | $32.96 | $52.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.51 / $186.56 / $272.36
| Professional | | $124.51 | $186.56 | $272.36 |