- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.58 / $2,941.58 / $6,907.00
| Facility | | $2,941.58 | $2,941.58 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.55 / $92.31 / $103.74
| Professional | | $62.55 | $92.31 | $103.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.81 / $97.30 / $138.32
| Professional | | $68.81 | $97.30 | $138.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.39 / $105.50 / $115.30
| Professional | | $64.39 | $105.50 | $115.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.65 / $117.48 / $276.61
| Professional | | $86.65 | $117.48 | $276.61 |