- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,053.30 / $22,053.30 / $22,053.30
| Facility | | $22,053.30 | $22,053.30 | $22,053.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,951.27 / $17,548.83 / $17,548.83
| Facility | | $16,951.27 | $17,548.83 | $17,548.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,351.44 / $14,586.12 / $28,002.80
| Facility | | $10,351.44 | $14,586.12 | $28,002.80 |
- 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
- $10,351.44 / $14,586.12 / $26,785.14
| Facility | | $10,351.44 | $14,586.12 | $26,785.14 |