- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,587.60 / $22,587.60 / $22,587.60
| Facility | | $22,587.60 | $22,587.60 | $22,587.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,361.97 / $17,974.00 / $17,974.00
| Facility | | $17,361.97 | $17,974.00 | $17,974.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,602.24 / $14,939.52 / $28,868.65
| Facility | | $10,602.24 | $14,939.52 | $28,868.65 |
- 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
- $10,602.24 / $14,939.52 / $27,434.10
| Facility | | $10,602.24 | $14,939.52 | $27,434.10 |