- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,121.12 / $5,121.12 / $5,121.12
| Facility | | $5,121.12 | $5,121.12 | $5,121.12 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $159.78 / $159.78 / $241.43
| Facility | 52 | $159.78 | $159.78 | $241.43 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $63.91 / $63.91 / $96.57
| Facility | 53 | $63.91 | $63.91 | $96.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $337.20 / $373.94 / $407.42
| Facility | | $337.20 | $373.94 | $407.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.56 / $362.56 / $362.56
| Facility | | $362.56 | $362.56 | $362.56 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $283.33 / $283.33 / $283.33
| Facility | 52 | $283.33 | $283.33 | $283.33 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $70.84 / $70.84 / $70.84
| Facility | 53 | $70.84 | $70.84 | $70.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,291.73 / $10,291.73 / $10,291.73
| Facility | | $10,291.73 | $10,291.73 | $10,291.73 |