- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,720.50 / $14,720.50 / $14,720.50
| Facility | | $14,720.50 | $14,720.50 | $14,720.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,314.90 / $11,713.76 / $11,713.76
| Facility | | $11,314.90 | $11,713.76 | $11,713.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,909.54 / $9,736.17 / $18,440.82
| Facility | | $6,909.54 | $9,736.17 | $18,440.82 |
- 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
- $6,909.54 / $9,736.17 / $17,878.96
| Facility | | $6,909.54 | $9,736.17 | $17,878.96 |