- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.66 / $134.52 / $134.52
| Professional | | $129.66 | $134.52 | $134.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $185.01
| Facility | | $162.08 | $162.08 | $185.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $185.01
| Professional | | $162.08 | $162.08 | $185.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.66 / $162.08 / $162.08
| Facility | | $129.66 | $162.08 | $162.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $175.84 / $2,250,000.00
| Professional | | $162.08 | $175.84 | $2,250,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $162.08
| Professional | | $162.08 | $162.08 | $162.08 |