- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,868.73 / $1,868.73
| Facility | | $1,400.00 | $1,868.73 | $1,868.73 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $373.75 / $373.75 / $373.75
| Facility | 53 | $373.75 | $373.75 | $373.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,880.01 / $1,880.01 / $2,337.27
| Facility | | $1,880.01 | $1,880.01 | $2,337.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,020.20 / $2,020.20 / $2,020.20
| Facility | | $2,020.20 | $2,020.20 | $2,020.20 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $394.00 / $394.00 / $394.00
| Facility | 53 | $394.00 | $394.00 | $394.00 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $1,231.24 / $1,231.24 / $1,231.24
| Facility | 62 | $1,231.24 | $1,231.24 | $1,231.24 |