- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,072.50 / $13,072.50 / $13,072.50
| Facility | | $13,072.50 | $13,072.50 | $13,072.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,048.20 / $10,402.41 / $10,402.41
| Facility | | $10,048.20 | $10,402.41 | $10,402.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,136.02 / $8,646.20 / $16,719.36
| Facility | | $6,136.02 | $8,646.20 | $16,719.36 |
- 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
- $6,136.02 / $8,646.20 / $15,877.42
| Facility | | $6,136.02 | $8,646.20 | $15,877.42 |