- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,751.20 / $20,751.20 / $20,751.20
| Facility | | $20,751.20 | $20,751.20 | $20,751.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,950.45 / $16,512.73 / $16,512.73
| Facility | | $15,950.45 | $16,512.73 | $16,512.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,740.28 / $13,724.94 / $22,022.08
| Facility | | $9,740.28 | $13,724.94 | $22,022.08 |
- 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
- $9,740.28 / $13,724.94 / $25,203.71
| Facility | | $9,740.28 | $13,724.94 | $25,203.71 |