- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,288.25 / $1,288.25
| Facility | | $758.58 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $1,995.26 / $2,630.27
| Facility | | $1.00 | $1,995.26 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $1.00 / $1.58
| Professional | | $0.02 | $1.00 | $1.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.88 / $34.67 / $53,703.18
| Facility | | $33.88 | $34.67 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $85.11 / $85.11
| Professional | | $85.11 | $85.11 | $85.11 |