- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,438.26 / $3,706.14 / $4,026.21
| Facility | | $3,438.26 | $3,706.14 | $4,026.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.15 / $946.67 / $1,152.41
| Professional | | $687.15 | $946.67 | $1,152.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.27 / $739.14 / $1,859.88
| Professional | | $628.27 | $739.14 | $1,859.88 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $103.48 / $147.83 / $371.98
| Professional | 55 | $103.48 | $147.83 | $371.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.72 / $973.39 / $1,608.02
| Professional | | $603.72 | $973.39 | $1,608.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,599.00 / $8,699.00 / $12,680.00
| Facility | | $3,599.00 | $8,699.00 | $12,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.77 / $1,159.15 / $1,480.03
| Professional | | $772.77 | $1,159.15 | $1,480.03 |