- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $2,754.23 / $13,489.63
| Facility | | $549.54 | $2,754.23 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $549.54 / $1,288.25
| Professional | | $346.74 | $549.54 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $977.24 / $1,949.84
| Facility | | $446.68 | $977.24 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $165.96 / $165.96 / $165.96
| Facility | AS | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $870.96 / $1,445.44
| Professional | | $676.08 | $870.96 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,548.13
| Facility | | $1,148.15 | $1,621.81 | $3,548.13 |