- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.00 / $2,500.00 / $2,500.00
| Professional | | $1,500.00 | $2,500.00 | $2,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,701.88 / $3,002.09 / $3,422.38
| Professional | | $2,701.88 | $3,002.09 | $3,422.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,591.11 / $1,591.11 / $1,591.11
| Professional | | $1,591.11 | $1,591.11 | $1,591.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,002.09 / $3,602.51 / $4,503.14
| Professional | | $3,002.09 | $3,602.51 | $4,503.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.88 / $1,501.05 / $2,731.84
| Professional | | $1,260.88 | $1,501.05 | $2,731.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,501.05 / $1,501.05 / $1,501.05
| Professional | | $1,501.05 | $1,501.05 | $1,501.05 |