- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,648.59 / $20,648.59 / $20,648.59
| Facility | | $20,648.59 | $20,648.59 | $20,648.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,871.55 / $16,431.05 / $16,431.05
| Facility | | $15,871.55 | $16,431.05 | $16,431.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,692.10 / $13,657.05 / $25,905.62
| Facility | | $9,692.10 | $13,657.05 | $25,905.62 |
- 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
- $9,692.10 / $13,657.05 / $25,079.04
| Facility | | $9,692.10 | $13,657.05 | $25,079.04 |