- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,943.40 / $11,943.40 / $11,943.40
| Facility | | $11,943.40 | $11,943.40 | $11,943.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,180.32 / $9,503.94 / $9,503.94
| Facility | | $9,180.32 | $9,503.94 | $9,503.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,606.04 / $7,899.42 / $13,985.17
| Facility | | $5,606.04 | $7,899.42 | $13,985.17 |
- 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
- $5,606.04 / $7,899.42 / $14,506.05
| Facility | | $5,606.04 | $7,899.42 | $14,506.05 |