- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,773.41 / $5,773.41 / $5,773.41
| Facility | | $5,773.41 | $5,773.41 | $5,773.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,099.67 / $5,773.41 / $5,773.41
| Professional | | $4,099.67 | $5,773.41 | $5,773.41 |
- 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
- $8,967.06 / $11,868.17 / $13,186.85
| Professional | | $8,967.06 | $11,868.17 | $13,186.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,356.91 / $10,356.91 / $10,950.30
| Facility | | $10,356.91 | $10,356.91 | $10,950.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,356.91 / $10,356.91 / $10,356.91
| Professional | | $10,356.91 | $10,356.91 | $10,356.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,503.37 / $7,503.37 / $8,309.74
| Facility | | $7,503.37 | $7,503.37 | $8,309.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,477.46 / $7,503.37 / $8,114.98
| Professional | | $5,477.46 | $7,503.37 | $8,114.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,454.70 / $5,182.05 / $7,081.25
| Professional | | $3,454.70 | $5,182.05 | $7,081.25 |