- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,257.92 / $5,257.92 / $5,257.92
| Facility | | $5,257.92 | $5,257.92 | $5,257.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.26 / $1,294.26 / $1,375.15
| Professional | | $1,294.26 | $1,294.26 | $1,375.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.92 / $1,172.92 / $1,303.24
| Facility | | $1,172.92 | $1,172.92 | $1,303.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Facility | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,429.07 / $1,429.07 / $1,429.07
| Professional | | $1,429.07 | $1,429.07 | $1,429.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.02 / $1,388.63 / $1,388.63
| Professional | | $540.02 | $1,388.63 | $1,388.63 |