- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $529.07 / $712.50 / $1,877.17
| Professional | AA | $529.07 | $712.50 | $1,877.17 |
- Facility/Professional
- Professional
- Modifier
- QX
- Low / Median / High Price
- $302.70 / $390.51 / $612.44
| Professional | QX | $302.70 | $390.51 | $612.44 |
- Facility/Professional
- Professional
- Modifier
- QY
- Low / Median / High Price
- $287.74 / $373.07 / $612.44
| Professional | QY | $287.74 | $373.07 | $612.44 |
- Facility/Professional
- Professional
- Modifier
- QX
- Low / Median / High Price
- $120.00 / $120.00 / $120.00
| Professional | QX | $120.00 | $120.00 | $120.00 |
- Facility/Professional
- Professional
- Modifier
- QY
- Low / Median / High Price
- $240.00 / $240.00 / $240.00
| Professional | QY | $240.00 | $240.00 | $240.00 |