- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $171.94 / $172.22 / $11,306.36
| Facility | | $171.94 | $172.22 | $11,306.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $172.22 / $295.74
| Professional | | $172.22 | $172.22 | $295.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,863.89 / $8,329.65 / $11,206.05
| Facility | | $6,863.89 | $8,329.65 | $11,206.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.36 / $172.22 / $172.22
| Professional | | $147.36 | $172.22 | $172.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.22 / $172.22 / $172.22
| Facility | | $172.22 | $172.22 | $172.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $172.22 / $205.14
| Professional | | $172.22 | $172.22 | $205.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $172.22 / $172.22
| Professional | | $172.22 | $172.22 | $172.22 |