- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,137.96 / $5,248.07
| Facility | | $1,258.93 | $2,137.96 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,137.96 / $4,168.69
| Facility | | $1,380.38 | $2,137.96 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $912.01 / $1,698.24
| Facility | | $575.44 | $912.01 | $1,698.24 |