- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.00 / $48.00 / $555.00
| Facility | | $48.00 | $48.00 | $555.00 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $146.21 / $146.21 / $146.21
| Professional | AA | $146.21 | $146.21 | $146.21 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Low / Median / High Price
- $2,201.50 / $2,201.50 / $2,201.50
| Professional | QZ | $2,201.50 | $2,201.50 | $2,201.50 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $581.79 / $581.79 / $661.13
| Professional | AA | $581.79 | $581.79 | $661.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.89 / $346.15 / $625.00
| Professional | | $306.89 | $346.15 | $625.00 |