- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,827.10 / $2,827.10 / $2,827.10
| Facility | | $2,827.10 | $2,827.10 | $2,827.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,827.10 / $2,827.10 / $3,068.22
| Professional | | $2,827.10 | $2,827.10 | $3,068.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,384.12 / $3,384.12 / $3,384.12
| Facility | | $3,384.12 | $3,384.12 | $3,384.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,384.12 / $3,384.12 / $3,384.12
| Professional | | $3,384.12 | $3,384.12 | $3,384.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $4,987.50
| Professional | | $4,200.00 | $4,200.00 | $4,987.50 |