- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $61.66 / $81.28
| Professional | | $48.98 | $61.66 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $56.23 / $107.15
| Professional | | $48.98 | $56.23 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $89.13 / $112.20
| Professional | | $69.18 | $89.13 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $79.43 / $100.00
| Professional | | $63.10 | $79.43 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.50 / $63.10 / $93.33
| Professional | | $5.50 | $63.10 | $93.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $63.10 / $85.11
| Professional | | $54.95 | $63.10 | $85.11 |