- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $242.15 / $242.15 / $274.92
| Facility | 54 | $242.15 | $242.15 | $274.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.52 / $322.87 / $366.56
| Professional | | $257.52 | $322.87 | $366.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.95 / $370.41 / $1,021.00
| Professional | | $336.95 | $370.41 | $1,021.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.63 / $458.12 / $965.26
| Professional | | $317.63 | $458.12 | $965.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.08 / $813.06 / $813.06
| Professional | | $717.08 | $813.06 | $813.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.40 / $437.22 / $984.40
| Professional | | $239.40 | $437.22 | $984.40 |