- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,120.10 / $5,120.10 / $5,120.10
| Professional | | $5,120.10 | $5,120.10 | $5,120.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.00 / $80.00 / $80.00
| Facility | | $80.00 | $80.00 | $80.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,120.10 / $5,120.10 / $6,912.15
| Facility | | $5,120.10 | $5,120.10 | $6,912.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,120.10 / $5,120.10 / $8,192.18
| Facility | | $5,120.10 | $5,120.10 | $8,192.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800,000.00 / $2,400,000.00 / $2,400,000.00
| Professional | | $1,800,000.00 | $2,400,000.00 | $2,400,000.00 |