- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $973.77 / $973.77 / $973.77
| Facility | | $973.77 | $973.77 | $973.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.77 / $973.77 / $3,822.00
| Professional | | $973.77 | $973.77 | $3,822.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,853.42 / $2,853.42 / $2,853.42
| Professional | | $2,853.42 | $2,853.42 | $2,853.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $973.77 / $973.77 / $1,645.67
| Facility | | $973.77 | $973.77 | $1,645.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.02 / $1,420.02 / $1,420.02
| Professional | | $1,420.02 | $1,420.02 | $1,420.02 |