- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,008.29 / $6,008.29 / $6,008.29
| Professional | | $6,008.29 | $6,008.29 | $6,008.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.92 / $165.92 / $165.92
| Facility | | $165.92 | $165.92 | $165.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.75 / $164.68 / $165.92
| Professional | | $131.75 | $164.68 | $165.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.92 / $165.92 / $165.92
| Facility | | $165.92 | $165.92 | $165.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.43 / $137.32 / $165.92
| Professional | | $114.43 | $137.32 | $165.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.06 / $48.06 / $114.43
| Professional | | $48.06 | $48.06 | $114.43 |