- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.05 / $36.31 / $57.54
| Professional | | $19.05 | $36.31 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.95 / $36.31 / $54.95
| Professional | | $19.95 | $36.31 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $43.65 / $54.95
| Professional | | $34.67 | $43.65 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.55 / $33.11 / $43.65
| Professional | | $24.55 | $33.11 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $39.81 / $46.77
| Professional | | $25.70 | $39.81 | $46.77 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.88 / $24.55 / $33.11
| Professional | | $21.88 | $24.55 | $33.11 |