- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,319.10 / $11,319.10 / $11,319.10
| Facility | | $11,319.10 | $11,319.10 | $11,319.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,700.44 / $9,007.15 / $9,007.15
| Facility | | $8,700.44 | $9,007.15 | $9,007.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,313.00 / $7,486.50 / $13,910.03
| Facility | | $5,313.00 | $7,486.50 | $13,910.03 |
- 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
- $5,313.00 / $7,486.50 / $13,747.79
| Facility | | $5,313.00 | $7,486.50 | $13,747.79 |