- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,005.70 / $21,005.70 / $21,005.70
| Facility | | $21,005.70 | $21,005.70 | $21,005.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,146.07 / $16,715.25 / $16,715.25
| Facility | | $16,146.07 | $16,715.25 | $16,715.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,859.74 / $13,893.27 / $24,476.19
| Facility | | $9,859.74 | $13,893.27 | $24,476.19 |
- 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
- $9,859.74 / $13,893.27 / $25,512.82
| Facility | | $9,859.74 | $13,893.27 | $25,512.82 |