- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,703.30 / $15,703.30 / $15,703.30
| Facility | | $15,703.30 | $15,703.30 | $15,703.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,944.64 / $12,495.88 / $12,495.88
| Facility | | $10,944.64 | $12,495.88 | $12,495.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,300.00 / $8,264.32 / $18,133.41
| Facility | | $4,300.00 | $8,264.32 | $18,133.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.00 / $950.00 / $950.00
| Facility | | $950.00 | $950.00 | $950.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,300.00 / $8,264.32 / $19,072.71
| Facility | | $4,300.00 | $8,264.32 | $19,072.71 |