- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24,425.40 / $24,425.40 / $24,425.40
| Facility | | $24,425.40 | $24,425.40 | $24,425.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18,774.58 / $19,436.41 / $19,436.41
| Facility | | $18,774.58 | $19,436.41 | $19,436.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,464.86 / $16,155.03 / $28,598.82
| Facility | | $11,464.86 | $16,155.03 | $28,598.82 |
- 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
- $11,464.86 / $16,155.03 / $29,666.19
| Facility | | $11,464.86 | $16,155.03 | $29,666.19 |