- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,822.70 / $21,822.70 / $21,822.70
| Facility | | $21,822.70 | $21,822.70 | $21,822.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,774.02 / $17,365.33 / $17,365.33
| Facility | | $16,774.02 | $17,365.33 | $17,365.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,243.20 / $14,433.60 / $26,428.21
| Facility | | $10,243.20 | $14,433.60 | $26,428.21 |
- 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
- $10,243.20 / $14,433.60 / $26,505.06
| Facility | | $10,243.20 | $14,433.60 | $26,505.06 |