- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $5,370.32 / $7,943.28
| Facility | | $363.08 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $389.05 / $1,862.09
| Professional | | $245.47 | $389.05 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $602.56 / $5,248.07
| Facility | | $363.08 | $602.56 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Facility | AS | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $616.60 / $707.95
| Professional | | $562.34 | $616.60 | $707.95 |
- 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 |