- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,792.70 / $12,792.70 / $12,792.70
| Facility | | $12,792.70 | $12,792.70 | $12,792.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,833.12 / $10,179.75 / $10,179.75
| Facility | | $9,833.12 | $10,179.75 | $10,179.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,004.68 / $8,461.14 / $16,063.57
| Facility | | $6,004.68 | $8,461.14 | $16,063.57 |
- 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
- $6,004.68 / $8,461.14 / $15,537.56
| Facility | | $6,004.68 | $8,461.14 | $15,537.56 |