- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,344.70 / $10,344.70 / $10,344.70
| Facility | | $10,344.70 | $10,344.70 | $10,344.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,951.45 / $8,231.75 / $8,231.75
| Facility | | $7,951.45 | $8,231.75 | $8,231.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,855.62 / $6,842.01 / $12,625.77
| Facility | | $4,855.62 | $6,842.01 | $12,625.77 |
- 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
- $4,855.62 / $6,842.01 / $12,564.28
| Facility | | $4,855.62 | $6,842.01 | $12,564.28 |