- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.10 / $318.75 / $638.00
| Professional | | $266.10 | $318.75 | $638.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $349.56 / $477.73 / $1,328.33
| Facility | | $349.56 | $477.73 | $1,328.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.00 / $777.11 / $777.11
| Professional | | $586.00 | $777.11 | $777.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $266.10 / $396.17 / $688.63
| Facility | | $266.10 | $396.17 | $688.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.11 / $2,400,000.00 / $2,400,000.00
| Professional | | $777.11 | $2,400,000.00 | $2,400,000.00 |