- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,197.03 / $1,197.03 / $8,500.00
| Facility | | $1,197.03 | $1,197.03 | $8,500.00 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $598.52 / $598.52 / $598.52
| Facility | 52 | $598.52 | $598.52 | $598.52 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $239.41 / $239.41 / $239.41
| Facility | 53 | $239.41 | $239.41 | $239.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,123.08 / $1,552.08 / $2,585.27
| Facility | | $1,123.08 | $1,552.08 | $2,585.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.00 / $681.00 / $681.00
| Facility | | $681.00 | $681.00 | $681.00 |