- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,314.60 / $12,314.60 / $12,314.60
| Facility | | $12,314.60 | $12,314.60 | $12,314.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,465.65 / $9,799.33 / $9,799.33
| Facility | | $9,465.65 | $9,799.33 | $9,799.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,780.28 / $8,144.94 / $15,180.63
| Facility | | $5,780.28 | $8,144.94 | $15,180.63 |
- 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
- $5,780.28 / $8,144.94 / $14,956.91
| Facility | | $5,780.28 | $8,144.94 | $14,956.91 |