- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30,979.11 / $30,979.11 / $30,979.11
| Facility | | $30,979.11 | $30,979.11 | $30,979.11 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $626.28 / $626.28 / $956.28
| Facility | 52 | $626.28 | $626.28 | $956.28 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $250.51 / $250.51 / $382.51
| Facility | 53 | $250.51 | $250.51 | $382.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,299.67 / $1,481.14 / $1,613.72
| Facility | | $1,299.67 | $1,481.14 | $1,613.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,391.39 / $1,391.39 / $1,391.39
| Facility | | $1,391.39 | $1,391.39 | $1,391.39 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $1,091.32 / $1,091.32 / $1,091.32
| Facility | 52 | $1,091.32 | $1,091.32 | $1,091.32 |
- Facility/Professional
- Facility
- Modifier
- 53
- Low / Median / High Price
- $272.83 / $272.83 / $272.83
| Facility | 53 | $272.83 | $272.83 | $272.83 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $136.41 / $136.41 / $136.41
| Facility | AS | $136.41 | $136.41 | $136.41 |