- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,893.13 / $3,893.13 / $3,893.13
| Facility | | $3,893.13 | $3,893.13 | $3,893.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,634.87 / $3,893.13 / $3,893.13
| Professional | | $2,634.87 | $3,893.13 | $3,893.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219,999.78 / $539,999.46 / $949,999.05
| Facility | | $219,999.78 | $539,999.46 | $949,999.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,046.68 / $8,002.96 / $8,892.18
| Professional | | $6,046.68 | $8,002.96 | $8,892.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,111.24 / $6,111.24 / $6,152.41
| Facility | | $6,111.24 | $6,111.24 | $6,152.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,111.24 / $6,111.24 / $6,111.24
| Professional | | $6,111.24 | $6,111.24 | $6,111.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,728.96 / $4,728.96 / $5,603.44
| Facility | | $4,728.96 | $4,728.96 | $5,603.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.14 / $4,728.96 / $5,472.11
| Professional | | $3,452.14 | $4,728.96 | $5,472.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,926.06 / $6,926.06 / $8,148.31
| Facility | | $6,926.06 | $6,926.06 | $8,148.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.55 / $3,494.36 / $4,698.14
| Professional | | $2,032.55 | $3,494.36 | $4,698.14 |