- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,616.10 / $10,616.10 / $10,616.10
| Facility | | $10,616.10 | $10,616.10 | $10,616.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,160.04 / $8,447.70 / $8,447.70
| Facility | | $8,160.04 | $8,447.70 | $8,447.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,983.00 / $7,021.50 / $13,144.94
| Facility | | $4,983.00 | $7,021.50 | $13,144.94 |
- 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
- $5,521.32 / $7,893.53 / $12,919.56
| Facility | | $5,521.32 | $7,893.53 | $12,919.56 |