- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.08 / $832.57 / $1,325.17
| Professional | | $599.08 | $832.57 | $1,325.17 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $113.17 / $124.89 / $626.05
| Professional | 55 | $113.17 | $124.89 | $626.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.05 / $1,183.55 / $2,989.15
| Professional | | $1,004.05 | $1,183.55 | $2,989.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.19 / $1,244.58 / $1,432.71
| Professional | | $746.19 | $1,244.58 | $1,432.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.19 / $1,140.00 / $1,432.71
| Professional | | $746.19 | $1,140.00 | $1,432.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.06 / $1,065.97 / $3,237.81
| Professional | | $868.06 | $1,065.97 | $3,237.81 |