- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,864.04 / $8,864.04 / $8,864.04
| Facility | | $8,864.04 | $8,864.04 | $8,864.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,813.36 / $7,053.55 / $7,053.55
| Facility | | $6,813.36 | $7,053.55 | $7,053.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,160.64 / $5,862.72 / $10,873.56
| Facility | | $4,160.64 | $5,862.72 | $10,873.56 |
- 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
- $4,160.64 / $5,862.72 / $10,765.97
| Facility | | $4,160.64 | $5,862.72 | $10,765.97 |