- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,498.30 / $14,498.30 / $14,498.30
| Facility | | $14,498.30 | $14,498.30 | $14,498.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,144.13 / $11,536.98 / $11,536.98
| Facility | | $11,144.13 | $11,536.98 | $11,536.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,805.26 / $9,589.23 / $17,933.61
| Facility | | $6,805.26 | $9,589.23 | $17,933.61 |
- 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
- $6,805.26 / $9,589.23 / $17,609.13
| Facility | | $6,805.26 | $9,589.23 | $17,609.13 |