- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $691.83 / $1,412.54 / $3,090.30
| Professional | AA | $691.83 | $1,412.54 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $120.23 / $457.09 / $1,047.13
| Professional | AA | $120.23 | $457.09 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- QK
- Low / Median / High Price
- $39.81 / $39.81 / $52.48
| Facility | QK | $39.81 | $39.81 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- QX
- Low / Median / High Price
- $39.81 / $39.81 / $52.48
| Facility | QX | $39.81 | $39.81 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- QY
- Low / Median / High Price
- $39.81 / $39.81 / $52.48
| Facility | QY | $39.81 | $39.81 | $52.48 |