- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $1,584.89
| Facility | | $741.31 | $741.31 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $977.24
| Facility | | $794.33 | $794.33 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,659.59
| Facility | | $1,288.25 | $1,288.25 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | 54 | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $4,466.84
| Facility | | $691.83 | $691.83 | $4,466.84 |