- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,703.30 / $15,703.30 / $15,703.30
| Facility | | $15,703.30 | $15,703.30 | $15,703.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,070.37 / $12,495.88 / $12,495.88
| Facility | | $12,070.37 | $12,495.88 | $12,495.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,370.88 / $10,386.24 / $20,259.87
| Facility | | $7,370.88 | $10,386.24 | $20,259.87 |
- 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
- $7,370.88 / $10,386.24 / $19,072.71
| Facility | | $7,370.88 | $10,386.24 | $19,072.71 |