- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,528.70 / $16,528.70 / $16,528.70
| Facility | | $16,528.70 | $16,528.70 | $16,528.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,704.80 / $13,152.67 / $13,152.67
| Facility | | $12,704.80 | $13,152.67 | $13,152.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,758.30 / $10,932.15 / $19,438.18
| Facility | | $7,758.30 | $10,932.15 | $19,438.18 |
- 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
- $7,758.30 / $10,932.15 / $20,075.18
| Facility | | $7,758.30 | $10,932.15 | $20,075.18 |