- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,746.10 / $5,746.10 / $5,746.10
| Facility | | $5,746.10 | $5,746.10 | $5,746.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,423.59 / $5,746.10 / $5,746.10
| Professional | | $4,423.59 | $5,746.10 | $5,746.10 |
- 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
- $8,924.62 / $11,812.01 / $13,124.46
| Professional | | $8,924.62 | $11,812.01 | $13,124.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,036.81 / $10,036.81 / $10,338.95
| Facility | | $10,036.81 | $10,036.81 | $10,338.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,036.81 / $10,036.81 / $10,036.81
| Professional | | $10,036.81 | $10,036.81 | $10,036.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,652.12 / $6,652.12 / $8,270.43
| Facility | | $6,652.12 | $6,652.12 | $8,270.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,856.05 / $6,652.12 / $8,076.59
| Professional | | $4,856.05 | $6,652.12 | $8,076.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,067.77 / $5,157.53 / $7,041.76
| Professional | | $3,067.77 | $5,157.53 | $7,041.76 |