- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $5,858.97 / $5,858.97
| Facility | | $1,400.00 | $5,858.97 | $5,858.97 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $571.88 / $571.88 / $571.88
| Facility | 54 | $571.88 | $571.88 | $571.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $789.46 / $858.52 / $935.37
| Facility | | $789.46 | $858.52 | $935.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.89 / $851.89 / $851.89
| Facility | | $851.89 | $851.89 | $851.89 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $596.32 / $596.32 / $596.32
| Facility | 54 | $596.32 | $596.32 | $596.32 |