- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.01 / $358.28 / $590.92
| Professional | | $280.01 | $358.28 | $590.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.00 / $376.68 / $459.49
| Professional | | $360.00 | $376.68 | $459.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $420.01 / $420.01 / $420.01
| Facility | | $420.01 | $420.01 | $420.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.61 / $306.61 / $420.01
| Professional | | $306.61 | $306.61 | $420.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.52 / $672.17 / $967.92
| Professional | | $470.52 | $672.17 | $967.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.77 / $346.33 / $531.75
| Professional | | $302.77 | $346.33 | $531.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.73 / $406.73 / $470.52
| Professional | | $406.73 | $406.73 | $470.52 |