- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,375.50 / $21,375.50 / $21,375.50
| Facility | | $21,375.50 | $21,375.50 | $21,375.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,430.32 / $17,009.52 / $17,009.52
| Facility | | $16,430.32 | $17,009.52 | $17,009.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,033.32 / $14,137.86 / $26,084.94
| Facility | | $10,033.32 | $14,137.86 | $26,084.94 |
- 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
- $10,033.32 / $14,137.86 / $25,961.98
| Facility | | $10,033.32 | $14,137.86 | $25,961.98 |