- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,018.50 / $10,018.50 / $10,018.50
| Facility | | $10,018.50 | $10,018.50 | $10,018.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,700.70 / $7,972.16 / $7,972.16
| Facility | | $7,700.70 | $7,972.16 | $7,972.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,702.50 / $6,626.25 / $11,894.83
| Facility | | $4,702.50 | $6,626.25 | $11,894.83 |
- 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
- $4,702.50 / $6,626.25 / $12,168.08
| Facility | | $4,702.50 | $6,626.25 | $12,168.08 |