- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.46 / $109.41 / $109.41
| Professional | | $105.46 | $109.41 | $109.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $112.05
| Facility | | $112.05 | $112.05 | $112.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $112.05
| Professional | | $112.05 | $112.05 | $112.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.46 / $105.46 / $112.05
| Facility | | $105.46 | $105.46 | $112.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.05 / $112.05 / $2,400,000.00
| Professional | | $112.05 | $112.05 | $2,400,000.00 |