- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,700.00 / $4,275.00 / $5,000.00
| Professional | | $3,700.00 | $4,275.00 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,000.00 / $4,000.00 / $4,560.00
| Professional | | $4,000.00 | $4,000.00 | $4,560.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,650.00 / $2,650.00 / $2,650.00
| Professional | | $2,650.00 | $2,650.00 | $2,650.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,000.00 / $6,000.00 / $7,500.00
| Professional | | $5,000.00 | $6,000.00 | $7,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,100.00 / $2,250.00 / $4,549.89
| Professional | | $2,100.00 | $2,250.00 | $4,549.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $3,975.00 / $3,975.00
| Professional | | $2,500.00 | $3,975.00 | $3,975.00 |