- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,991.50 / $10,991.50 / $10,991.50
| Facility | | $10,991.50 | $10,991.50 | $10,991.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,448.61 / $8,746.44 / $8,746.44
| Facility | | $8,448.61 | $8,746.44 | $8,746.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,159.22 / $7,269.81 / $13,344.75
| Facility | | $5,159.22 | $7,269.81 | $13,344.75 |
- 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
- $5,716.57 / $8,172.67 / $13,376.45
| Facility | | $5,716.57 | $8,172.67 | $13,376.45 |