- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,051.70 / $12,051.70 / $12,051.70
| Facility | | $12,051.70 | $12,051.70 | $12,051.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,263.54 / $9,590.09 / $9,590.09
| Facility | | $9,263.54 | $9,590.09 | $9,590.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,656.86 / $7,971.03 / $15,107.20
| Facility | | $5,656.86 | $7,971.03 | $15,107.20 |
- 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
- $5,656.86 / $7,971.03 / $14,637.55
| Facility | | $5,656.86 | $7,971.03 | $14,637.55 |