- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.09 / $28.76 / $119.91
| Professional | | $25.09 | $28.76 | $119.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.70 / $28.64 / $44.72
| Professional | | $21.70 | $28.64 | $44.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.26 / $45.13 / $53.88
| Professional | | $39.26 | $45.13 | $53.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.34 / $29.81 / $34.78
| Professional | | $25.34 | $29.81 | $34.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.34 / $31.05 / $44.28
| Professional | | $25.34 | $31.05 | $44.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.60 / $27.92 / $51.70
| Professional | | $19.60 | $27.92 | $51.70 |