- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.20 / $555.20 / $555.20
| Professional | | $555.20 | $555.20 | $555.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $523.78 / $3,166.54 / $5,277.56
| Facility | | $523.78 | $3,166.54 | $5,277.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.20 / $555.20 / $5,277.56
| Professional | | $555.20 | $555.20 | $5,277.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $523.78 / $3,166.54 / $5,277.56
| Facility | | $523.78 | $3,166.54 | $5,277.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.20 / $555.20 / $5,277.56
| Professional | | $555.20 | $555.20 | $5,277.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.20 / $588.51 / $1,665.60
| Professional | | $555.20 | $588.51 | $1,665.60 |