- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,400.00 / $5,400.00 / $5,621.40
| Professional | | $5,400.00 | $5,400.00 | $5,621.40 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $125.16 / $125.16 / $125.16
| Professional | 55 | $125.16 | $125.16 | $125.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,411.00 / $3,897.00 / $4,676.00
| Professional | | $2,411.00 | $3,897.00 | $4,676.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.87 / $1,027.17 / $1,483.69
| Professional | | $760.87 | $1,027.17 | $1,483.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.97 / $1,377.02 / $2,404.65
| Professional | | $774.97 | $1,377.02 | $2,404.65 |