- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,207.20 / $14,207.20 / $14,207.20
| Facility | | $14,207.20 | $14,207.20 | $14,207.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,920.40 / $11,305.37 / $11,305.37
| Facility | | $10,920.40 | $11,305.37 | $11,305.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,668.64 / $9,396.71 / $17,964.34
| Facility | | $6,668.64 | $9,396.71 | $17,964.34 |
- 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
- $6,668.64 / $9,396.71 / $17,255.61
| Facility | | $6,668.64 | $9,396.71 | $17,255.61 |