- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,494.10 / $14,494.10 / $14,494.10
| Facility | | $14,494.10 | $14,494.10 | $14,494.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,140.89 / $11,533.62 / $11,533.62
| Facility | | $11,140.89 | $11,533.62 | $11,533.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,803.28 / $9,586.44 / $17,802.11
| Facility | | $6,803.28 | $9,586.44 | $17,802.11 |
- 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
- $6,803.28 / $9,586.44 / $17,604.00
| Facility | | $6,803.28 | $9,586.44 | $17,604.00 |