- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,162.28 / $9,332.54
| Facility | | $891.25 | $3,162.28 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,168.69 / $10,000.00
| Facility | | $1,548.82 | $4,168.69 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,318.26 / $4,897.79
| Facility | | $776.25 | $1,318.26 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | 54 | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,258.93 / $3,981.07
| Facility | | $302.00 | $1,258.93 | $3,981.07 |