- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,560.62 / $5,560.62 / $5,560.62
| Facility | | $5,560.62 | $5,560.62 | $5,560.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,056.17 / $5,560.62 / $5,979.44
| Professional | | $5,056.17 | $5,560.62 | $5,979.44 |
- 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
- $10,544.11 / $13,955.44 / $15,506.04
| Professional | | $10,544.11 | $13,955.44 | $15,506.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,551.49 / $7,551.49 / $7,551.49
| Facility | | $7,551.49 | $7,551.49 | $7,551.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,418.77 / $7,551.49 / $12,417.25
| Professional | | $6,418.77 | $7,551.49 | $12,417.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,705.97 / $7,401.57 / $13,800.39
| Professional | | $3,705.97 | $7,401.57 | $13,800.39 |