- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.55 / $446.25 / $2,132.59
| Professional | | $369.55 | $446.25 | $2,132.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,132.59 / $2,132.59 / $5,540.14
| Professional | | $2,132.59 | $2,132.59 | $5,540.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.59 / $2,231.29 / $5,540.14
| Professional | | $508.59 | $2,231.29 | $5,540.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.59 / $2,231.29 / $5,540.14
| Professional | | $508.59 | $2,231.29 | $5,540.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,152.94 / $2,572.19 / $6,799.91
| Professional | | $2,152.94 | $2,572.19 | $6,799.91 |