- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $70.79 / $95.50
| Professional | | $38.90 | $70.79 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $75.86 / $102.33 / $102.33
| Professional | 25 | $75.86 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.15 / $63.10 / $89.13
| Professional | | $37.15 | $63.10 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $91.20 / $107.15
| Professional | | $72.44 | $91.20 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $75.86 / $109.65
| Professional | | $42.66 | $75.86 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $57.54 / $109.65
| Professional | | $38.02 | $57.54 | $109.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $74.13 / $109.65
| Professional | | $41.69 | $74.13 | $109.65 |