- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,568.20 / $10,568.20 / $10,568.20
| Facility | | $10,568.20 | $10,568.20 | $10,568.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,123.29 / $8,409.65 / $8,409.65
| Facility | | $8,123.29 | $8,409.65 | $8,409.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,960.56 / $6,989.88 / $12,765.81
| Facility | | $4,960.56 | $6,989.88 | $12,765.81 |
- 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
- $4,960.56 / $6,989.88 / $12,835.82
| Facility | | $4,960.56 | $6,989.88 | $12,835.82 |