- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,674.23 / $8,674.23 / $8,674.23
| Facility | | $8,674.23 | $8,674.23 | $8,674.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,667.46 / $6,902.49 / $6,902.49
| Facility | | $6,667.46 | $6,902.49 | $6,902.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,071.54 / $5,737.17 / $10,658.38
| Facility | | $4,071.54 | $5,737.17 | $10,658.38 |
- 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
- $4,071.54 / $5,737.17 / $10,535.42
| Facility | | $4,071.54 | $5,737.17 | $10,535.42 |