- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,803.10 / $10,803.10 / $10,803.10
| Facility | | $10,803.10 | $10,803.10 | $10,803.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,303.79 / $8,596.51 / $8,596.51
| Facility | | $8,303.79 | $8,596.51 | $8,596.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,070.78 / $7,145.19 / $13,298.64
| Facility | | $5,070.78 | $7,145.19 | $13,298.64 |
- 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
- $5,070.78 / $7,145.19 / $13,121.03
| Facility | | $5,070.78 | $7,145.19 | $13,121.03 |