- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,071.60 / $11,071.60 / $11,071.60
| Facility | | $11,071.60 | $11,071.60 | $11,071.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,510.21 / $8,810.21 / $8,810.21
| Facility | | $8,510.21 | $8,810.21 | $8,810.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,196.84 / $7,322.82 / $14,284.22
| Facility | | $5,196.84 | $7,322.82 | $14,284.22 |
- 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
- $5,196.84 / $7,322.82 / $13,447.22
| Facility | | $5,196.84 | $7,322.82 | $13,447.22 |