- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,958.53 / $7,958.53 / $7,958.53
| Facility | | $7,958.53 | $7,958.53 | $7,958.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,117.33 / $6,332.97 / $6,332.97
| Facility | | $6,117.33 | $6,332.97 | $6,332.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,735.60 / $5,263.80 / $9,370.70
| Facility | | $3,735.60 | $5,263.80 | $9,370.70 |
- 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
- $3,735.60 / $5,263.80 / $9,666.15
| Facility | | $3,735.60 | $5,263.80 | $9,666.15 |