- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $245.47
| Facility | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,659.59 / $3,801.89
| Facility | | $794.33 | $1,659.59 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $2,187.76
| Facility | | $645.65 | $912.01 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $870.96 / $1,737.80
| Facility | | $707.95 | $870.96 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $436.52 / $6,025.60
| Facility | | $269.15 | $436.52 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,370.32 / $10,000.00
| Facility | | $1,584.89 | $5,370.32 | $10,000.00 |