- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $3,090.30 / $6,309.57
| Facility | | $389.05 | $3,090.30 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $2,691.53 / $3,801.89
| Facility | | $630.96 | $2,691.53 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Facility | AS | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $380.19 / $549.54
| Professional | | $288.40 | $380.19 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $3,630.78
| Facility | | $1,230.27 | $1,862.09 | $3,630.78 |