- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.94 / $703.37 / $1,090.59
| Professional | | $584.94 | $703.37 | $1,090.59 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $105.51 / $122.27 / $138.09
| Professional | 55 | $105.51 | $122.27 | $138.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.40 / $952.91 / $2,450.46
| Professional | | $808.40 | $952.91 | $2,450.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.47 / $1,130.81 / $1,456.87
| Professional | | $777.47 | $1,130.81 | $1,456.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.89 / $1,110.00 / $1,456.87
| Professional | | $625.89 | $1,110.00 | $1,456.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.74 / $1,014.34 / $2,870.70
| Professional | | $834.74 | $1,014.34 | $2,870.70 |