- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26,915.60 / $26,915.60 / $26,915.60
| Facility | | $26,915.60 | $26,915.60 | $26,915.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,688.66 / $21,417.98 / $21,417.98
| Facility | | $20,688.66 | $21,417.98 | $21,417.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,633.72 / $17,802.06 / $31,833.39
| Facility | | $12,633.72 | $17,802.06 | $31,833.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.00 / $1,450.00 / $1,450.00
| Facility | | $1,450.00 | $1,450.00 | $1,450.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,633.72 / $17,802.06 / $32,690.71
| Facility | | $12,633.72 | $17,802.06 | $32,690.71 |