- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,594.80 / $16,594.80 / $16,594.80
| Facility | | $16,594.80 | $16,594.80 | $16,594.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,755.60 / $13,205.26 / $13,205.26
| Facility | | $12,755.60 | $13,205.26 | $13,205.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,789.32 / $10,975.86 / $19,863.41
| Facility | | $7,789.32 | $10,975.86 | $19,863.41 |
- 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
- $7,789.32 / $10,975.86 / $20,155.46
| Facility | | $7,789.32 | $10,975.86 | $20,155.46 |