- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $324.14 / $486.23 / $1,040.00
| Professional | AA | $324.14 | $486.23 | $1,040.00 |
- Facility/Professional
- Professional
- Modifier
- QX
- Low / Median / High Price
- $108.85 / $108.85 / $207.80
| Professional | QX | $108.85 | $108.85 | $207.80 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Low / Median / High Price
- $158.32 / $158.32 / $158.32
| Professional | QZ | $158.32 | $158.32 | $158.32 |
- Facility/Professional
- Professional
- Modifier
- QX
- Low / Median / High Price
- $180.00 / $180.00 / $180.00
| Professional | QX | $180.00 | $180.00 | $180.00 |
- Facility/Professional
- Professional
- Modifier
- QY
- Low / Median / High Price
- $180.00 / $180.00 / $180.00
| Professional | QY | $180.00 | $180.00 | $180.00 |