- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,088.20 / $12,088.20 / $12,088.20
| Facility | | $12,088.20 | $12,088.20 | $12,088.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,291.64 / $9,619.18 / $9,619.18
| Facility | | $9,291.64 | $9,619.18 | $9,619.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,674.02 / $7,995.21 / $15,595.82
| Facility | | $5,674.02 | $7,995.21 | $15,595.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.00 / $1,450.00 / $1,450.00
| Facility | | $1,450.00 | $1,450.00 | $1,450.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,674.02 / $7,995.21 / $14,681.96
| Facility | | $5,674.02 | $7,995.21 | $14,681.96 |