- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,737.51 / $8,737.51 / $8,737.51
| Facility | | $8,737.51 | $8,737.51 | $8,737.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,716.09 / $6,952.84 / $6,952.84
| Facility | | $6,716.09 | $6,952.84 | $6,952.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,101.24 / $5,779.02 / $10,504.68
| Facility | | $4,101.24 | $5,779.02 | $10,504.68 |
- 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
- $4,101.24 / $5,779.02 / $10,612.27
| Facility | | $4,101.24 | $5,779.02 | $10,612.27 |