- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $512.86 / $870.96
| Facility | | $56.23 | $512.86 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $128.82 / $602.56 / $1,258.93
| Professional | AA | $128.82 | $602.56 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- QX
- Low / Median / High Price
- $234.42 / $302.00 / $398.11
| Professional | QX | $234.42 | $302.00 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- QY
- Low / Median / High Price
- $251.19 / $288.40 / $331.13
| Professional | QY | $251.19 | $288.40 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Low / Median / High Price
- $95.50 / $524.81 / $660.69
| Professional | QZ | $95.50 | $524.81 | $660.69 |