- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.12 / $358.12 / $358.12
| Facility | | $358.12 | $358.12 | $358.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $667.52 / $702.65 / $2,248.35
| Facility | | $667.52 | $702.65 | $2,248.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.91 / $1,359.27 / $3,269.90
| Facility | | $870.91 | $1,359.27 | $3,269.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.91 / $1,118.65 / $2,574.73
| Facility | | $870.91 | $1,118.65 | $2,574.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.12 / $607.20 / $1,067.20
| Facility | | $358.12 | $607.20 | $1,067.20 |