- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,209.60 / $21,209.60 / $21,209.60
| Facility | | $21,209.60 | $21,209.60 | $21,209.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,302.79 / $16,877.49 / $16,877.49
| Facility | | $16,302.79 | $16,877.49 | $16,877.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,955.44 / $14,028.12 / $24,964.62
| Facility | | $9,955.44 | $14,028.12 | $24,964.62 |
- 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
- $11,030.93 / $15,536.52 / $25,811.74
| Facility | | $11,030.93 | $15,536.52 | $25,811.74 |