- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,000.00 / $5,750.00 / $10,000.00
| Facility | | $5,000.00 | $5,750.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,900.00 / $5,750.00 / $5,750.00
| Professional | | $3,900.00 | $5,750.00 | $5,750.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.89 / $652.76 / $878.17
| Facility | | $537.89 | $652.76 | $878.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,250.00 / $4,062.50 / $10,822.50
| Facility | | $3,250.00 | $4,062.50 | $10,822.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,100.00 / $3,000.00
| Professional | | $2,100.00 | $2,100.00 | $3,000.00 |