- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $60.26 / $91.20
| Professional | | $15.85 | $60.26 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.84 / $44.67 / $75.86
| Professional | | $28.84 | $44.67 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $64.57 / $75.86
| Professional | | $56.23 | $64.57 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.60 / $39.81 / $57.54
| Professional | | $16.60 | $39.81 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.91 / $41.69 / $75.86
| Professional | | $22.91 | $41.69 | $75.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.98 / $22.91 / $38.90
| Professional | | $16.98 | $22.91 | $38.90 |