- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,817.92 / $7,817.92 / $7,817.92
| Facility | | $7,817.92 | $7,817.92 | $7,817.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,009.25 / $6,221.08 / $6,221.08
| Facility | | $6,009.25 | $6,221.08 | $6,221.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,669.60 / $5,170.80 / $9,683.23
| Facility | | $3,669.60 | $5,170.80 | $9,683.23 |
- 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
- $3,669.60 / $5,170.80 / $9,495.37
| Facility | | $3,669.60 | $5,170.80 | $9,495.37 |