- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,632.90 / $10,632.90 / $10,632.90
| Facility | | $10,632.90 | $10,632.90 | $10,632.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,173.01 / $8,461.12 / $8,461.12
| Facility | | $8,173.01 | $8,461.12 | $8,461.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,990.92 / $7,032.66 / $12,811.92
| Facility | | $4,990.92 | $7,032.66 | $12,811.92 |
- 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
- $4,990.92 / $7,032.66 / $12,914.38
| Facility | | $4,990.92 | $7,032.66 | $12,914.38 |