- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $251.19 / $1,071.52
| Professional | | $100.00 | $251.19 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $2,511.89
| Professional | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $501.19 / $2,630.27
| Professional | | $144.54 | $501.19 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $851.14 / $1,621.81
| Professional | | $676.08 | $851.14 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $616.60 / $1,479.11
| Professional | | $112.20 | $616.60 | $1,479.11 |