- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $196.85 / $428.16 / $661.52
| Facility | 54 | $196.85 | $428.16 | $661.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.52 / $315.85 / $528.76
| Professional | | $257.52 | $315.85 | $528.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.29 / $405.39 / $648.71
| Professional | | $291.29 | $405.39 | $648.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.76 / $418.15 / $639.84
| Professional | | $310.76 | $418.15 | $639.84 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $989.74 / $1,118.17 / $1,118.17
| Facility | 54 | $989.74 | $1,118.17 | $1,118.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,220.71 / $2,554.08 / $2,979.75
| Professional | | $2,220.71 | $2,554.08 | $2,979.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.08 / $357.34 / $681.19
| Professional | | $285.08 | $357.34 | $681.19 |