- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.93 / $491.93 / $491.93
| Professional | | $491.93 | $491.93 | $491.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $2,200.00 / $2,200.00
| Facility | | $2,200.00 | $2,200.00 | $2,200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.66 / $2,200.00 / $4,255.87
| Professional | | $354.66 | $2,200.00 | $4,255.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $4,421.70 / $6,809.39
| Facility | | $2,200.00 | $4,421.70 | $6,809.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.66 / $2,200.00 / $4,255.87
| Professional | | $354.66 | $2,200.00 | $4,255.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.48 / $2,263.38 / $3,772.30
| Professional | | $2,170.48 | $2,263.38 | $3,772.30 |