- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $6,309.57
| Facility | | $6,309.57 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $10,964.78 / $16,982.44
| Facility | | $6,760.83 | $10,964.78 | $16,982.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,054.61 / $25,118.86 / $26,302.68
| Facility | | $19,054.61 | $25,118.86 | $26,302.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,309.57 / $6,309.57 / $14,791.08
| Facility | | $6,309.57 | $6,309.57 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $9,549.93 / $14,791.08
| Facility | | $6,760.83 | $9,549.93 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,244.36 / $9,332.54 / $10,000.00
| Facility | | $7,244.36 | $9,332.54 | $10,000.00 |