- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.30 / $688.42 / $3,188.69
| Professional | | $607.30 | $688.42 | $3,188.69 |
- Facility/Professional
- Professional
- Modifier
- 54
- Low / Median / High Price
- $455.48 / $572.27 / $2,391.52
| Professional | 54 | $455.48 | $572.27 | $2,391.52 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $91.10 / $114.45 / $478.30
| Professional | 55 | $91.10 | $114.45 | $478.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.84 / $988.81 / $2,511.87
| Professional | | $838.84 | $988.81 | $2,511.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.91 / $1,001.38 / $1,215.30
| Professional | | $599.91 | $1,001.38 | $1,215.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.44 / $937.68 / $1,215.30
| Professional | | $550.44 | $937.68 | $1,215.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.97 / $837.44 / $2,829.92
| Professional | | $760.97 | $837.44 | $2,829.92 |