- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,649.18 / $7,649.18 / $7,649.18
| Facility | | $7,649.18 | $7,649.18 | $7,649.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,879.55 / $6,086.82 / $6,086.82
| Facility | | $5,879.55 | $6,086.82 | $6,086.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,590.40 / $5,059.20 / $9,345.08
| Facility | | $3,590.40 | $5,059.20 | $9,345.08 |
- 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
- $3,590.40 / $5,059.20 / $9,290.43
| Facility | | $3,590.40 | $5,059.20 | $9,290.43 |