- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.80 / $169.60 / $280.36
| Professional | | $130.80 | $169.60 | $280.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.03 / $215.02 / $334.14
| Professional | | $155.03 | $215.02 | $334.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.70 / $222.06 / $349.81
| Professional | | $167.70 | $222.06 | $349.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,134.88 / $1,359.20 / $1,575.60
| Professional | | $1,134.88 | $1,359.20 | $1,575.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.44 / $201.58 / $378.86
| Professional | | $156.44 | $201.58 | $378.86 |