- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $478.63 / $676.08 / $1,000.00
| Professional | AA | $478.63 | $676.08 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Low / Median / High Price
- $676.08 / $724.44 / $1,122.02
| Professional | QZ | $676.08 | $724.44 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $416.87 / $478.63 / $524.81
| Professional | AA | $416.87 | $478.63 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- AA
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | AA | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- QZ
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Professional | QZ | $346.74 | $346.74 | $346.74 |