- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,021.80 / $8,021.80 / $8,021.80
| Facility | | $8,021.80 | $8,021.80 | $8,021.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.96 / $6,383.32 / $6,383.32
| Facility | | $6,165.96 | $6,383.32 | $6,383.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,765.30 / $5,305.65 / $10,349.44
| Facility | | $3,765.30 | $5,305.65 | $10,349.44 |
- 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
- $3,765.30 / $5,305.65 / $9,743.00
| Facility | | $3,765.30 | $5,305.65 | $9,743.00 |