- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.55 / $30.86 / $125.23
| Professional | | $27.55 | $30.86 | $125.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.86 / $32.86 / $47.84
| Professional | | $32.86 | $32.86 | $47.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.36 / $48.67 / $2,376.00
| Professional | | $39.36 | $48.67 | $2,376.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.10 / $45.92 / $53.58
| Professional | | $42.10 | $45.92 | $53.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.36 / $37.36 / $54.57
| Professional | | $37.36 | $37.36 | $54.57 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $48.31 / $3,580.00
| Professional | | $29.27 | $48.31 | $3,580.00 |