- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Facility | | $50.00 | $50.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $470.40 / $571.95 / $1,208.64
| Professional | AA | $470.40 | $571.95 | $1,208.64 |
- Facility/Professional
- Professional
- Modifier
- QK
- Low / Median / High Price
- $162.50 / $311.02 / $405.02
| Professional | QK | $162.50 | $311.02 | $405.02 |
- Facility/Professional
- Professional
- Modifier
- QX
- Low / Median / High Price
- $120.04 / $120.04 / $415.54
| Professional | QX | $120.04 | $120.04 | $415.54 |
- Facility/Professional
- Professional
- Modifier
- QY
- Low / Median / High Price
- $326.07 / $326.07 / $326.07
| Professional | QY | $326.07 | $326.07 | $326.07 |