- Facility/Professional
- Facility
- Modifier
- QX
- Low / Median / High Price
- $604.52 / $604.52 / $760.28
| Facility | QX | $604.52 | $604.52 | $760.28 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $397.70 / $1,400.00 / $2,100.00
| Professional | AA | $397.70 | $1,400.00 | $2,100.00 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Low / Median / High Price
- $306.55 / $306.55 / $306.55
| Professional | QZ | $306.55 | $306.55 | $306.55 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $231.86 / $231.86 / $897.00
| Professional | AA | $231.86 | $231.86 | $897.00 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Low / Median / High Price
- $135.59 / $213.07 / $213.07
| Professional | QZ | $135.59 | $213.07 | $213.07 |