- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.41 / $932.63 / $1,434.55
| Professional | | $738.41 | $932.63 | $1,434.55 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $136.16 / $154.44 / $718.19
| Professional | 55 | $136.16 | $154.44 | $718.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,884.63 / $2,048.71 / $3,237.66
| Professional | | $1,884.63 | $2,048.71 | $3,237.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.68 / $1,391.98 / $1,672.51
| Professional | | $826.68 | $1,391.98 | $1,672.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.68 / $1,328.64 / $1,672.51
| Professional | | $826.68 | $1,328.64 | $1,672.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.07 / $1,167.15 / $3,725.42
| Professional | | $879.07 | $1,167.15 | $3,725.42 |