- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,157.60 / $21,157.60 / $21,157.60
| Facility | | $21,157.60 | $21,157.60 | $21,157.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,262.80 / $16,836.09 / $16,836.09
| Facility | | $16,262.80 | $16,836.09 | $16,836.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,931.02 / $13,993.71 / $25,424.02
| Facility | | $9,931.02 | $13,993.71 | $25,424.02 |
- 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
- $9,931.02 / $13,993.71 / $25,697.27
| Facility | | $9,931.02 | $13,993.71 | $25,697.27 |