- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,728.40 / $16,728.40 / $16,728.40
| Facility | | $16,728.40 | $16,728.40 | $16,728.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,858.28 / $13,311.55 / $13,311.55
| Facility | | $12,858.28 | $13,311.55 | $13,311.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,852.02 / $11,064.21 / $18,427.16
| Facility | | $7,852.02 | $11,064.21 | $18,427.16 |
- 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
- $7,852.02 / $11,064.21 / $20,317.70
| Facility | | $7,852.02 | $11,064.21 | $20,317.70 |