- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $5,370.32 / $7,943.28
| Facility | | $537.03 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $512.86 / $1,412.54
| Professional | | $331.13 | $512.86 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $954.99 / $6,606.93
| Facility | | $537.03 | $954.99 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $158.49 / $158.49 / $158.49
| Facility | AS | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $851.14 / $1,621.81
| Professional | | $776.25 | $851.14 | $1,621.81 |
- 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 |