- Facility/Professional
- Facility
- Modifier
- QX
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | QX | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $489.78 / $933.25 / $1,698.24
| Professional | AA | $489.78 | $933.25 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Low / Median / High Price
- $223.87 / $660.69 / $1,096.48
| Professional | QZ | $223.87 | $660.69 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $173.78 / $524.81 / $1,380.38
| Professional | AA | $173.78 | $524.81 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Low / Median / High Price
- $141.25 / $575.44 / $1,174.90
| Professional | QZ | $141.25 | $575.44 | $1,174.90 |