- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.42 / $37.42 / $50.00
| Professional | | $37.42 | $37.42 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.65 / $45.03 / $54.03
| Professional | | $35.65 | $45.03 | $54.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.49 / $57.13 / $65.34
| Professional | | $49.49 | $57.13 | $65.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $38.18 / $45.03
| Professional | | $20.00 | $38.18 | $45.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.74 / $45.03 / $58.47
| Professional | | $36.74 | $45.03 | $58.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.35 / $32.72 / $60.55
| Professional | | $16.35 | $32.72 | $60.55 |