- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $5,495.41 / $9,772.37
| Facility | | $5,495.41 | $5,495.41 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $6,309.57 / $10,715.19
| Professional | | $5,495.41 | $6,309.57 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $10,232.93
| Professional | | $9,549.93 | $9,549.93 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Facility | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,606.93 / $6,606.93 / $9,120.11
| Professional | | $6,606.93 | $6,606.93 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66,069.34 / $66,069.34 / $66,069.34
| Facility | | $66,069.34 | $66,069.34 | $66,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81,283.05 / $93,325.43 / $93,325.43
| Professional | | $81,283.05 | $93,325.43 | $93,325.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $8,128.31 / $9,332.54
| Facility | | $4,677.35 | $8,128.31 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,309.57 / $9,120.11
| Professional | | $4,265.80 | $6,309.57 | $9,120.11 |