- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,591.60 / $12,591.60 / $12,591.60
| Facility | | $12,591.60 | $12,591.60 | $12,591.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,678.56 / $10,019.75 / $10,019.75
| Facility | | $9,678.56 | $10,019.75 | $10,019.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,910.30 / $8,328.15 / $15,264.32
| Facility | | $5,910.30 | $8,328.15 | $15,264.32 |
- 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
- $5,910.30 / $8,328.15 / $15,293.35
| Facility | | $5,910.30 | $8,328.15 | $15,293.35 |