- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $723.85 / $723.85 / $723.85
| Facility | | $723.85 | $723.85 | $723.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,376.20 / $2,958.82 / $5,867.17
| Facility | | $1,376.20 | $2,958.82 | $5,867.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,612.09 / $2,286.15 / $5,499.64
| Facility | | $1,612.09 | $2,286.15 | $5,499.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,310.52 / $2,090.09 / $4,330.43
| Facility | | $1,310.52 | $2,090.09 | $4,330.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $892.55 / $1,332.79 / $3,500.00
| Facility | | $892.55 | $1,332.79 | $3,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,751.00 / $3,500.00 / $8,152.00
| Facility | | $1,751.00 | $3,500.00 | $8,152.00 |