- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,467.60 / $13,467.60 / $13,467.60
| Facility | | $13,467.60 | $13,467.60 | $13,467.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,386.44 / $10,716.82 / $10,716.82
| Facility | | $9,386.44 | $10,716.82 | $10,716.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,300.00 / $7,087.72 / $14,917.63
| Facility | | $4,300.00 | $7,087.72 | $14,917.63 |
- 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
- $4,300.00 / $7,087.72 / $16,357.31
| Facility | | $4,300.00 | $7,087.72 | $16,357.31 |