- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,420.47 / $7,420.47 / $7,420.47
| Facility | | $7,420.47 | $7,420.47 | $7,420.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,447.01 / $7,420.47 / $7,420.47
| Professional | | $5,447.01 | $7,420.47 | $7,420.47 |
- 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
- $11,525.21 / $15,253.96 / $16,948.84
| Professional | | $11,525.21 | $15,253.96 | $16,948.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,762.21 / $12,762.21 / $12,867.13
| Facility | | $12,762.21 | $12,762.21 | $12,867.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,762.21 / $12,762.21 / $12,762.21
| Professional | | $12,762.21 | $12,762.21 | $12,762.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,077.06 / $9,077.06 / $10,680.38
| Facility | | $9,077.06 | $9,077.06 | $10,680.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,626.25 / $9,077.06 / $10,430.06
| Professional | | $6,626.25 | $9,077.06 | $10,430.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,440.27 / $6,660.40 / $9,208.84
| Professional | | $4,440.27 | $6,660.40 | $9,208.84 |