- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,167.50 / $10,167.50 / $10,167.50
| Facility | | $10,167.50 | $10,167.50 | $10,167.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,815.26 / $8,090.77 / $8,090.77
| Facility | | $7,815.26 | $8,090.77 | $8,090.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,772.46 / $6,724.83 / $12,383.26
| Facility | | $4,772.46 | $6,724.83 | $12,383.26 |
- 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
- $4,772.46 / $6,724.83 / $12,349.10
| Facility | | $4,772.46 | $6,724.83 | $12,349.10 |