- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Facility | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $168.09
| Professional | | $161.62 | $161.62 | $168.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.62 / $482.44 / $758.53
| Facility | | $161.62 | $482.44 | $758.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $1,004.96
| Professional | | $161.62 | $161.62 | $1,004.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Facility | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Professional | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.62 / $242.83 / $8,090.00
| Facility | | $161.62 | $242.83 | $8,090.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Professional | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $161.62
| Professional | | $161.62 | $161.62 | $161.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $379.65 / $379.65 / $758.53
| Facility | | $379.65 | $379.65 | $758.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $1,004.96
| Professional | | $161.62 | $161.62 | $1,004.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.62 / $161.62 / $379.65
| Professional | | $161.62 | $161.62 | $379.65 |