- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.10 / $1,020.07 / $1,356.62
| Professional | | $761.10 | $1,020.07 | $1,356.62 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $131.66 / $153.01 / $173.12
| Professional | 55 | $131.66 | $153.01 | $173.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.65 / $1,192.51 / $3,062.30
| Professional | | $1,011.65 | $1,192.51 | $3,062.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.24 / $1,415.40 / $1,823.52
| Professional | | $967.24 | $1,415.40 | $1,823.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.00 / $1,389.35 / $1,823.52
| Professional | | $786.00 | $1,389.35 | $1,823.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.09 / $1,259.08 / $3,591.93
| Professional | | $905.09 | $1,259.08 | $3,591.93 |