- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,947.40 / $3,947.40 / $3,947.40
| Professional | | $3,947.40 | $3,947.40 | $3,947.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,505.76 / $8,505.76 / $10,893.38
| Facility | | $8,505.76 | $8,505.76 | $10,893.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,947.40 / $3,947.40 / $3,947.40
| Professional | | $3,947.40 | $3,947.40 | $3,947.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,947.40 / $3,947.40 / $3,947.40
| Professional | | $3,947.40 | $3,947.40 | $3,947.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,870.00 / $3,870.00 / $8,941.25
| Professional | | $3,870.00 | $3,870.00 | $8,941.25 |