- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.01 / $24.66 / $150.22
| Professional | | $22.01 | $24.66 | $150.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.30 / $26.30 / $38.33
| Professional | | $26.30 | $26.30 | $38.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.59 / $45.67 / $51.74
| Professional | | $39.59 | $45.67 | $51.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.72 / $36.79 / $42.92
| Professional | | $33.72 | $36.79 | $42.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.56 / $38.33 / $43.08
| Professional | | $29.56 | $38.33 | $43.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.97 / $36.69 / $129.75
| Professional | | $4.97 | $36.69 | $129.75 |