- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,421.12 / $8,421.12 / $8,421.12
| Facility | | $8,421.12 | $8,421.12 | $8,421.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,472.91 / $6,701.09 / $6,701.09
| Facility | | $6,472.91 | $6,701.09 | $6,701.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,952.74 / $5,569.77 / $9,587.59
| Facility | | $3,952.74 | $5,569.77 | $9,587.59 |
- 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
- $3,952.74 / $5,569.77 / $10,228.01
| Facility | | $3,952.74 | $5,569.77 | $10,228.01 |