- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.00 / $35.00 / $275.00
| Facility | | $35.00 | $35.00 | $275.00 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $146.21 / $146.21 / $146.21
| Professional | AA | $146.21 | $146.21 | $146.21 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $346.28 / $435.42 / $732.79
| Professional | AA | $346.28 | $435.42 | $732.79 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $257.14 / $417.75 / $1,025.50
| Professional | AA | $257.14 | $417.75 | $1,025.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $59.15 / $59.15 / $59.15
| Facility | | $59.15 | $59.15 | $59.15 |