- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $5,370.32 / $7,943.28
| Facility | | $257.04 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $257.04 / $724.44
| Professional | | $162.18 | $257.04 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $436.52 / $6,606.93
| Facility | | $204.17 | $436.52 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $77.62 / $77.62 / $77.62
| Facility | AS | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $407.38 / $616.60
| Professional | | $269.15 | $407.38 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |