- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,733.10 / $14,733.10 / $14,733.10
| Facility | | $14,733.10 | $14,733.10 | $14,733.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,324.62 / $11,723.83 / $11,723.83
| Facility | | $11,324.62 | $11,723.83 | $11,723.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,915.48 / $9,744.54 / $17,978.00
| Facility | | $6,915.48 | $9,744.54 | $17,978.00 |
- 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
- $6,915.48 / $9,744.54 / $17,894.33
| Facility | | $6,915.48 | $9,744.54 | $17,894.33 |