- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,083.10 / $21,083.10 / $21,083.10
| Facility | | $21,083.10 | $21,083.10 | $21,083.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,205.52 / $16,776.79 / $16,776.79
| Facility | | $16,205.52 | $16,776.79 | $16,776.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,896.04 / $13,944.42 / $25,775.83
| Facility | | $9,896.04 | $13,944.42 | $25,775.83 |
- 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
- $9,896.04 / $13,944.42 / $25,606.75
| Facility | | $9,896.04 | $13,944.42 | $25,606.75 |