- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,152.00 / $10,152.00 / $10,152.00
| Facility | | $10,152.00 | $10,152.00 | $10,152.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,803.38 / $8,078.46 / $8,078.46
| Facility | | $7,803.38 | $8,078.46 | $8,078.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,765.20 / $6,714.60 / $12,712.86
| Facility | | $4,765.20 | $6,714.60 | $12,712.86 |
- 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
- $4,765.20 / $6,714.60 / $12,330.32
| Facility | | $4,765.20 | $6,714.60 | $12,330.32 |