- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,861.60 / $12,861.60 / $12,861.60
| Facility | | $12,861.60 | $12,861.60 | $12,861.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,886.08 / $10,234.58 / $10,234.58
| Facility | | $9,886.08 | $10,234.58 | $10,234.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,037.02 / $8,506.70 / $15,096.95
| Facility | | $6,037.02 | $8,506.70 | $15,096.95 |
- 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
- $6,037.02 / $8,506.70 / $15,621.25
| Facility | | $6,037.02 | $8,506.70 | $15,621.25 |