- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,704.60 / $21,704.60 / $21,704.60
| Facility | | $21,704.60 | $21,704.60 | $21,704.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,683.23 / $17,271.34 / $17,271.34
| Facility | | $16,683.23 | $17,271.34 | $17,271.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,187.76 / $14,355.48 / $26,798.80
| Facility | | $10,187.76 | $14,355.48 | $26,798.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.00 / $950.00 / $950.00
| Facility | | $950.00 | $950.00 | $950.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,187.76 / $14,355.48 / $26,361.60
| Facility | | $10,187.76 | $14,355.48 | $26,361.60 |