- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $3,981.07
| Facility | | $3,467.37 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $954.99 / $1,513.56
| Professional | | $331.13 | $954.99 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $549.54 / $1,659.59
| Professional | | $467.74 | $549.54 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $93.33 / $109.65 / $331.13
| Professional | 55 | $93.33 | $109.65 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $977.24 / $1,995.26
| Professional | | $602.56 | $977.24 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,413.10 / $13,182.57
| Facility | | $3,235.94 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,202.26 / $1,698.24
| Professional | | $691.83 | $1,202.26 | $1,698.24 |