- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,617.50 / $10,617.50 / $10,617.50
| Facility | | $10,617.50 | $10,617.50 | $10,617.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,161.12 / $8,448.81 / $8,448.81
| Facility | | $8,161.12 | $8,448.81 | $8,448.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,983.66 / $7,022.43 / $12,820.45
| Facility | | $4,983.66 | $7,022.43 | $12,820.45 |
- 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
- $4,983.66 / $7,022.43 / $12,895.60
| Facility | | $4,983.66 | $7,022.43 | $12,895.60 |