- 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 / $1.66
| Professional | | $0.02 | $1.00 | $1.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50,118.72 / $50,118.72 / $53,703.18
| Facility | | $50,118.72 | $50,118.72 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $72.44 / $72.44
| Professional | | $72.44 | $72.44 | $72.44 |