- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.35 / $41.00 / $58.35
| Professional | | $25.35 | $41.00 | $58.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.85 / $40.00 / $58.00
| Professional | | $28.85 | $40.00 | $58.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.72 / $44.90 / $54.07
| Professional | | $33.72 | $44.90 | $54.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.70 / $40.39 / $47.52
| Professional | | $29.70 | $40.39 | $47.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.36 / $39.00 / $58.22
| Professional | | $29.36 | $39.00 | $58.22 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.99 / $31.71 / $42.91
| Professional | | $24.99 | $31.71 | $42.91 |