- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $147.91 / $223.87
| Facility | | $91.20 | $147.91 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,137.96 / $4,073.80
| Facility | | $1,905.46 | $2,137.96 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $2,089.30
| Facility | | $954.99 | $954.99 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $186.21 / $346.74
| Facility | | $100.00 | $186.21 | $346.74 |