- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $2,290.87 / $7,244.36
| Facility | | $162.18 | $2,290.87 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $245.47 / $512.86
| Facility | | $147.91 | $245.47 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $416.87 / $446.68
| Professional | | $407.38 | $416.87 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $309.03 / $363.08
| Professional | | $223.87 | $309.03 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $72.44 / $72.44 / $72.44
| Professional | AS | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |