- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.25 / $288.70 / $3,353.01
| Professional | | $239.25 | $288.70 | $3,353.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,353.01 / $3,353.01 / $7,567.40
| Professional | | $3,353.01 | $3,353.01 | $7,567.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.59 / $3,310.89 / $7,567.40
| Professional | | $331.59 | $3,310.89 | $7,567.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.59 / $3,310.89 / $7,567.40
| Professional | | $331.59 | $3,310.89 | $7,567.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,268.63 / $4,032.00 / $9,288.14
| Professional | | $3,268.63 | $4,032.00 | $9,288.14 |