- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.10 / $761.10 / $761.10
| Professional | | $761.10 | $761.10 | $761.10 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $127.71 / $127.71 / $127.71
| Professional | 55 | $127.71 | $127.71 | $127.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,492.00 / $4,029.00 / $4,835.00
| Professional | | $2,492.00 | $4,029.00 | $4,835.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.21 / $1,204.48 / $1,739.81
| Professional | | $892.21 | $1,204.48 | $1,739.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.40 / $1,723.91 / $3,217.48
| Professional | | $1,172.40 | $1,723.91 | $3,217.48 |