- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $2,511.89 / $8,511.38
| Facility | | $1,000.00 | $2,511.89 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,511.38 / $13,489.63
| Facility | | $4,265.80 | $8,511.38 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $1,288.25 / $5,011.87
| Facility | | $398.11 | $1,288.25 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,412.54 / $4,265.80
| Professional | | $776.25 | $1,412.54 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $4,265.80 / $7,585.78
| Facility | | $1,096.48 | $4,265.80 | $7,585.78 |