- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $479.00 / $479.00 / $479.00
| Facility | 54 | $479.00 | $479.00 | $479.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.07 / $305.98 / $523.29
| Professional | | $266.07 | $305.98 | $523.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.47 / $406.32 / $572.11
| Professional | | $315.47 | $406.32 | $572.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.27 / $479.92 / $694.88
| Professional | | $344.27 | $479.92 | $694.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.88 / $464.72 / $763.06
| Professional | | $387.88 | $464.72 | $763.06 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $479.00 / $479.00 / $479.00
| Facility | 54 | $479.00 | $479.00 | $479.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.07 / $359.20 / $584.90
| Professional | | $266.07 | $359.20 | $584.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.22 / $425.43 / $693.84
| Professional | | $311.22 | $425.43 | $693.84 |