- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.20 / $1,011.28 / $1,086.28
| Professional | | $775.20 | $1,011.28 | $1,086.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,411.77 / $1,411.77 / $1,411.77
| Facility | | $1,411.77 | $1,411.77 | $1,411.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.77 / $1,411.77 / $1,523.52
| Professional | | $1,411.77 | $1,411.77 | $1,523.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $868.98 / $1,156.08 / $1,411.77
| Facility | | $868.98 | $1,156.08 | $1,411.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.77 / $1,411.77 / $2,400,000.00
| Professional | | $1,411.77 | $1,411.77 | $2,400,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.77 / $1,308.77 / $1,308.77
| Professional | | $1,308.77 | $1,308.77 | $1,308.77 |