- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,304.80 / $2,304.80 / $2,304.80
| Facility | | $2,304.80 | $2,304.80 | $2,304.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,227.04
| Professional | | $1,227.04 | $1,227.04 | $1,227.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,754.67
| Facility | | $1,227.04 | $1,227.04 | $1,754.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,227.04 / $1,754.67
| Facility | | $1,227.04 | $1,227.04 | $1,754.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,250,000.00 / $2,250,000.00 / $2,400,000.00
| Professional | | $2,250,000.00 | $2,250,000.00 | $2,400,000.00 |