- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.96 / $22.91 / $56.23
| Professional | | $10.96 | $22.91 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $28.84 / $61.66 / $87.10
| Professional | 50 | $28.84 | $61.66 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $19.95 / $19.95 / $19.95
| Professional | 52 | $19.95 | $19.95 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $15.85 / $19.05
| Professional | | $15.85 | $15.85 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.75 / $21.88 / $56.23
| Professional | | $11.75 | $21.88 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.45 / $19.95 / $58.88
| Professional | | $14.45 | $19.95 | $58.88 |