- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.14 / $349.31 / $1,504.00
| Professional | | $269.14 | $349.31 | $1,504.00 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $816.74 / $816.74 / $2,346.00
| Professional | 50 | $816.74 | $816.74 | $2,346.00 |
- Facility/Professional
- Professional
- Modifier
- 54
- Low / Median / High Price
- $236.67 / $278.06 / $1,241.96
| Professional | 54 | $236.67 | $278.06 | $1,241.96 |
- Facility/Professional
- Professional
- Modifier
- 55
- Low / Median / High Price
- $47.33 / $55.61 / $248.39
| Professional | 55 | $47.33 | $55.61 | $248.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $648.54 / $688.86 / $1,082.84
| Facility | | $648.54 | $688.86 | $1,082.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.20 / $548.37 / $1,212.23
| Professional | | $465.20 | $548.37 | $1,212.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.39 / $517.86 / $583.90
| Professional | | $287.39 | $517.86 | $583.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.64 / $489.38 / $583.90
| Professional | | $282.64 | $489.38 | $583.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.70 / $403.16 / $1,371.43
| Professional | | $339.70 | $403.16 | $1,371.43 |