- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $917.02 / $917.02 / $917.02
| Facility | 50 | $917.02 | $917.02 | $917.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.76 / $258.56 / $620.79
| Professional | | $121.76 | $258.56 | $620.79 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $306.77 / $306.77 / $306.77
| Professional | 50 | $306.77 | $306.77 | $306.77 |
- Facility/Professional
- Professional
- Modifier
- 54
- Low / Median / High Price
- $153.22 / $153.22 / $185.41
| Professional | 54 | $153.22 | $153.22 | $185.41 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $30.65 / $30.65 / $37.08
| Professional | 55 | $30.65 | $30.65 | $37.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.00 / $967.00 / $1,161.00
| Professional | | $598.00 | $967.00 | $1,161.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $897.00 / $1,450.50 / $1,741.50
| Professional | 50 | $897.00 | $1,450.50 | $1,741.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.73 / $409.01 / $653.08
| Professional | | $343.73 | $409.01 | $653.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.22 / $486.88 / $1,105.00
| Professional | | $356.22 | $486.88 | $1,105.00 |