- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.92 / $79.92 / $196.12
| Professional | | $79.92 | $79.92 | $196.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.12 / $196.12 / $215.92
| Professional | | $196.12 | $196.12 | $215.92 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.92 / $79.92 / $91.96
| Professional | 26 | $79.92 | $79.92 | $91.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.67 / $181.02 / $215.92
| Professional | | $120.67 | $181.02 | $215.92 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $79.92 / $79.92 / $91.96
| Professional | 26 | $79.92 | $79.92 | $91.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.72 / $87.43 / $151.65
| Professional | | $82.72 | $87.43 | $151.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $34.65 / $35.22 / $63.52
| Professional | 26 | $34.65 | $35.22 | $63.52 |