- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,212.30 / $1,400.00 / $2,600.00
| Facility | | $1,212.30 | $1,400.00 | $2,600.00 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $909.23 / $909.23 / $1,410.65
| Facility | 54 | $909.23 | $909.23 | $1,410.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,300.46 / $1,456.60 / $1,586.98
| Facility | | $1,300.46 | $1,456.60 | $1,586.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,389.07 / $1,389.07 / $1,389.07
| Facility | | $1,389.07 | $1,389.07 | $1,389.07 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $964.30 / $964.30 / $964.30
| Facility | 54 | $964.30 | $964.30 | $964.30 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $137.76 / $137.76 / $137.76
| Facility | AS | $137.76 | $137.76 | $137.76 |