- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.31 / $371.75 / $714.81
| Professional | | $316.31 | $371.75 | $714.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $264.98 / $312.56 / $627.58
| Professional | TC | $264.98 | $312.56 | $627.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.34 / $361.71 / $674.31
| Professional | | $244.34 | $361.71 | $674.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $191.59 / $313.29 / $585.99
| Professional | TC | $191.59 | $313.29 | $585.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.91 / $319.08 / $897.73
| Professional | | $204.91 | $319.08 | $897.73 |
- Facility/Professional
- Professional
- Modifier
- TC
- Low / Median / High Price
- $161.12 / $278.27 / $765.25
| Professional | TC | $161.12 | $278.27 | $765.25 |