- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,687.60 / $11,875.10 / $11,875.10
| Facility | | $10,687.60 | $11,875.10 | $11,875.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,163.02 / $13,163.02 / $13,163.02
| Facility | | $13,163.02 | $13,163.02 | $13,163.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,443.60 / $10,309.89 / $25,721.35
| Facility | | $6,443.60 | $10,309.89 | $25,721.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,435.00 / $13,295.00 / $20,548.00
| Facility | | $9,435.00 | $13,295.00 | $20,548.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,965.00 / $17,741.05 / $22,906.67
| Facility | | $6,965.00 | $17,741.05 | $22,906.67 |