- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $2,048.07 / $2,048.07 / $2,395.40
| Professional | AA | $2,048.07 | $2,048.07 | $2,395.40 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $2,812.00 / $2,812.00 / $2,812.00
| Professional | AA | $2,812.00 | $2,812.00 | $2,812.00 |
- Facility/Professional
- Facility
- Modifier
- QK
- Low / Median / High Price
- $37.00 / $37.00 / $39.50
| Facility | QK | $37.00 | $37.00 | $39.50 |
- Facility/Professional
- Facility
- Modifier
- QX
- Low / Median / High Price
- $37.00 / $37.00 / $39.50
| Facility | QX | $37.00 | $37.00 | $39.50 |
- Facility/Professional
- Facility
- Modifier
- QY
- Low / Median / High Price
- $37.00 / $37.00 / $39.50
| Facility | QY | $37.00 | $37.00 | $39.50 |