- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,605.78 / $5,605.78 / $7,283.30
| Facility | | $5,605.78 | $5,605.78 | $7,283.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.08 / $1,077.18 / $1,371.62
| Professional | | $599.08 | $1,077.18 | $1,371.62 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $179.70 / $181.18 / $181.18
| Professional | 55 | $179.70 | $181.18 | $181.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.02 / $972.64 / $1,560.40
| Professional | | $786.02 | $972.64 | $1,560.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $531.64 / $531.64 / $531.64
| Facility | | $531.64 | $531.64 | $531.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.58 / $1,505.30 / $1,801.72
| Professional | | $997.58 | $1,505.30 | $1,801.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.65 / $1,158.91 / $1,777.83
| Professional | | $1,001.65 | $1,158.91 | $1,777.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,605.78 / $5,605.78 / $7,283.30
| Facility | | $5,605.78 | $5,605.78 | $7,283.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.08 / $974.61 / $1,528.89
| Professional | | $599.08 | $974.61 | $1,528.89 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $181.18 / $181.18 / $181.18
| Professional | 55 | $181.18 | $181.18 | $181.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.60 / $1,039.00 / $1,377.39
| Professional | | $752.60 | $1,039.00 | $1,377.39 |