- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.42 / $52.42 / $52.42
| Professional | | $52.42 | $52.42 | $52.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.50 / $43.50 / $43.50
| Professional | | $43.50 | $43.50 | $43.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.42 / $52.42 / $52.42
| Facility | | $52.42 | $52.42 | $52.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.42 / $52.42 / $52.42
| Facility | | $52.42 | $52.42 | $52.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.50 / $43.50 / $2,550,000.00
| Professional | | $43.50 | $43.50 | $2,550,000.00 |