- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.50 / $275.00 / $392.35
| Facility | | $43.50 | $275.00 | $392.35 |
- 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
- Facility
- Modifier
- Low / Median / High Price
- $44.24 / $58.19 / $112.56
| Facility | | $44.24 | $58.19 | $112.56 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $342.85 / $342.85 / $428.56
| Professional | AA | $342.85 | $342.85 | $428.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.50 / $80.48 / $3,480.00
| Facility | | $43.50 | $80.48 | $3,480.00 |