- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,375.20 / $17,375.20 / $17,375.20
| Facility | | $17,375.20 | $17,375.20 | $17,375.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,355.45 / $13,826.25 / $13,826.25
| Facility | | $13,355.45 | $13,826.25 | $13,826.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,155.62 / $11,492.01 / $22,416.83
| Facility | | $8,155.62 | $11,492.01 | $22,416.83 |
- 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
- $8,155.62 / $11,492.01 / $21,103.28
| Facility | | $8,155.62 | $11,492.01 | $21,103.28 |