- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,826.09 / $8,826.09 / $8,826.09
| Facility | | $8,826.09 | $8,826.09 | $8,826.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,784.18 / $7,023.34 / $7,023.34
| Facility | | $6,784.18 | $7,023.34 | $7,023.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,142.82 / $5,837.61 / $10,009.42
| Facility | | $4,142.82 | $5,837.61 | $10,009.42 |
- 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
- $4,142.82 / $5,837.61 / $10,719.86
| Facility | | $4,142.82 | $5,837.61 | $10,719.86 |