- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.85 / $192.85 / $192.85
| Facility | | $192.85 | $192.85 | $192.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.13 / $30.07 / $50.75
| Professional | | $11.13 | $30.07 | $50.75 |
- Facility/Professional
- Professional
- Modifier
- 52
- Low / Median / High Price
- $5.57 / $8.21 / $29.72
| Professional | 52 | $5.57 | $8.21 | $29.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $67.00
| Professional | | $17.00 | $20.00 | $67.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.01 / $35.72 / $77.20
| Professional | | $16.01 | $35.72 | $77.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.53 / $76.26 / $146.91
| Professional | | $53.53 | $76.26 | $146.91 |