- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $13,803.84
| Facility | | $8,511.38 | $8,511.38 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,495.41 / $6,918.31
| Professional | | $4,466.84 | $5,495.41 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $46,773.51 / $53,703.18 / $58,884.37
| Facility | | $46,773.51 | $53,703.18 | $58,884.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $5,128.61 / $7,943.28
| Professional | | $208.93 | $5,128.61 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,054.61 / $19,054.61 / $19,054.61
| Facility | | $19,054.61 | $19,054.61 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $10,232.93
| Professional | | $8,511.38 | $8,511.38 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $8,511.38
| Facility | | $8,511.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,888.44 / $8,511.38
| Professional | | $4,466.84 | $5,888.44 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,128.61 / $8,511.38
| Professional | | $2,187.76 | $5,128.61 | $8,511.38 |