- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.83 / $20.83 / $29.28
| Professional | | $20.83 | $20.83 | $29.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.83 / $20.83 / $29.79
| Facility | | $20.83 | $20.83 | $29.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.20 / $460.20 / $460.20
| Professional | | $460.20 | $460.20 | $460.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,495.87 / $3,495.87 / $3,495.87
| Facility | | $3,495.87 | $3,495.87 | $3,495.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.83 / $20.83 / $29.79
| Facility | | $20.83 | $20.83 | $29.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,400,000.00 / $2,400,000.00 / $2,400,000.00
| Professional | | $2,400,000.00 | $2,400,000.00 | $2,400,000.00 |