- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.27 / $129.27 / $129.27
| Facility | | $129.27 | $129.27 | $129.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.35 / $2,413.60 / $5,595.68
| Facility | | $562.35 | $2,413.60 | $5,595.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.95 / $439.55 / $1,057.40
| Facility | | $309.95 | $439.55 | $1,057.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.97 / $401.86 / $832.60
| Facility | | $251.97 | $401.86 | $832.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.65 / $2,903.00 / $5,920.00
| Facility | | $138.65 | $2,903.00 | $5,920.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,296.00 / $3,500.00 / $6,361.00
| Facility | | $2,296.00 | $3,500.00 | $6,361.00 |