- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,760.00
| Professional | | $2,000.00 | $2,000.00 | $2,760.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,024.96 / $4,528.08 / $5,162.01
| Professional | | $4,024.96 | $4,528.08 | $5,162.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,666.54 / $3,576.83 / $14,532.86
| Professional | | $2,666.54 | $3,576.83 | $14,532.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,031.20 / $6,037.44 / $7,546.80
| Professional | | $5,031.20 | $6,037.44 | $7,546.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,113.10 / $2,264.04 / $4,398.07
| Professional | | $2,113.10 | $2,264.04 | $4,398.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,515.60 / $3,999.80 / $3,999.80
| Professional | | $2,515.60 | $3,999.80 | $3,999.80 |