- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $6,606.93 / $8,128.31
| Facility | | $302.00 | $6,606.93 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $467.74 / $831.76
| Professional | | $245.47 | $467.74 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $660.69 / $2,344.23
| Facility | | $407.38 | $660.69 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Facility | AS | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $616.60 / $1,202.26
| Professional | | $549.54 | $616.60 | $1,202.26 |
- 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 |