- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $61.66 / $89.13
| Professional | | $41.69 | $61.66 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $60.26 / $100.00
| Professional | | $48.98 | $60.26 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $97.72 / $2,454.71
| Professional | | $77.62 | $97.72 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $77.62 / $97.72
| Professional | | $47.86 | $77.62 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $77.62 / $114.82
| Professional | | $60.26 | $77.62 | $114.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $63.10 / $112.20
| Professional | | $29.51 | $63.10 | $112.20 |