- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,501.40 / $13,501.40 / $13,501.40
| Facility | | $13,501.40 | $13,501.40 | $13,501.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,377.84 / $10,743.68 / $10,743.68
| Facility | | $10,377.84 | $10,743.68 | $10,743.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,337.32 / $8,929.86 / $16,370.97
| Facility | | $6,337.32 | $8,929.86 | $16,370.97 |
- 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
- $6,337.32 / $8,929.86 / $16,398.30
| Facility | | $6,337.32 | $8,929.86 | $16,398.30 |