- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,019.30 / $12,019.30 / $12,019.30
| Facility | | $12,019.30 | $12,019.30 | $12,019.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,238.68 / $9,564.36 / $9,564.36
| Facility | | $9,238.68 | $9,564.36 | $9,564.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,641.68 / $7,949.64 / $14,851.03
| Facility | | $5,641.68 | $7,949.64 | $14,851.03 |
- 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
- $5,641.68 / $7,949.64 / $14,598.27
| Facility | | $5,641.68 | $7,949.64 | $14,598.27 |