- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,583.60 / $21,583.60 / $21,583.60
| Facility | | $21,583.60 | $21,583.60 | $21,583.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,590.28 / $17,175.12 / $17,175.12
| Facility | | $16,590.28 | $17,175.12 | $17,175.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,131.00 / $14,275.50 / $26,216.44
| Facility | | $10,131.00 | $14,275.50 | $26,216.44 |
- 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
- $10,131.00 / $14,275.50 / $26,214.73
| Facility | | $10,131.00 | $14,275.50 | $26,214.73 |