- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,511.89 / $7,585.78
| Facility | | $398.11 | $2,511.89 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $645.65
| Professional | | $524.81 | $524.81 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $380.19 / $575.44
| Facility | | $269.15 | $380.19 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $758.58 / $1,949.84
| Facility | | $173.78 | $758.58 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $169.82 / $169.82 / $169.82
| Facility | AS | $169.82 | $169.82 | $169.82 |