- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,218.10 / $16,218.10 / $16,218.10
| Facility | | $16,218.10 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $13,489.63 / $16,218.10
| Professional | | $7,762.47 | $13,489.63 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,772.37 / $11,748.98 / $11,748.98
| Professional | | $9,772.37 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,489.63 / $13,489.63 / $14,125.38
| Facility | | $13,489.63 | $13,489.63 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,762.47 / $13,489.63 / $13,489.63
| Professional | | $7,762.47 | $13,489.63 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $13,489.63 / $2,691,534.80
| Facility | | $8,128.31 | $13,489.63 | $2,691,534.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $9,772.37 / $11,748.98
| Professional | | $79.43 | $9,772.37 | $11,748.98 |