- 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 / $1.00 / $1.95
| Facility | | $1.00 | $1.00 | $1.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $1.00 / $1.51
| Professional | | $0.02 | $1.00 | $1.51 |
- 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
- $151.36 / $251.19 / $524.81
| Professional | | $151.36 | $251.19 | $524.81 |