- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,759.20 / $11,759.20 / $11,759.20
| Facility | | $11,759.20 | $11,759.20 | $11,759.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,038.73 / $9,357.36 / $9,357.36
| Facility | | $9,038.73 | $9,357.36 | $9,357.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,519.58 / $7,777.59 / $14,519.72
| Facility | | $5,519.58 | $7,777.59 | $14,519.72 |
- 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
- $6,115.86 / $8,743.52 / $14,310.77
| Facility | | $6,115.86 | $8,743.52 | $14,310.77 |