- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,610.40 / $10,610.40 / $10,610.40
| Facility | | $10,610.40 | $10,610.40 | $10,610.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,155.72 / $8,443.21 / $8,443.21
| Facility | | $8,155.72 | $8,443.21 | $8,443.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,980.35 / $7,017.78 / $12,905.84
| Facility | | $4,980.35 | $7,017.78 | $12,905.84 |
- 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
- $4,980.35 / $7,017.78 / $12,887.06
| Facility | | $4,980.35 | $7,017.78 | $12,887.06 |