- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,162.06 / $5,162.06 / $5,162.06
| Facility | | $5,162.06 | $5,162.06 | $5,162.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,024.33 / $5,162.06 / $5,162.06
| Professional | | $4,024.33 | $5,162.06 | $5,162.06 |
- 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
- $8,017.53 / $10,611.43 / $11,790.48
| Professional | | $8,017.53 | $10,611.43 | $11,790.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,142.60 / $10,142.60 / $10,782.97
| Facility | | $10,142.60 | $10,142.60 | $10,782.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,142.60 / $10,142.60 / $10,142.60
| Professional | | $10,142.60 | $10,142.60 | $10,142.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,261.93 / $7,261.93 / $7,429.82
| Facility | | $7,261.93 | $7,261.93 | $7,429.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,301.21 / $5,301.21 / $7,261.93
| Professional | | $5,301.21 | $5,301.21 | $7,261.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,075.66 / $4,633.32 / $6,951.12
| Professional | | $3,075.66 | $4,633.32 | $6,951.12 |