- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,075.33 / $2,075.33 / $2,075.33
| Facility | | $2,075.33 | $2,075.33 | $2,075.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,667.09 / $2,075.33 / $2,075.33
| Professional | | $1,667.09 | $2,075.33 | $2,075.33 |
- 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
- $3,223.33 / $4,266.17 / $4,740.18
| Professional | | $3,223.33 | $4,266.17 | $4,740.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,703.47 / $3,703.47 / $3,892.65
| Facility | | $3,703.47 | $3,703.47 | $3,892.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,703.47 / $3,703.47 / $3,703.47
| Professional | | $3,703.47 | $3,703.47 | $3,703.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,970.85 / $2,970.85 / $2,987.05
| Facility | | $2,970.85 | $2,970.85 | $2,987.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,168.71 / $2,917.04 / $2,970.85
| Professional | | $2,168.71 | $2,917.04 | $2,970.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.83 / $1,862.76 / $2,847.13
| Professional | | $1,241.83 | $1,862.76 | $2,847.13 |