- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.12 / $36.03 / $139.00
| Professional | | $22.12 | $36.03 | $139.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.30 / $27.64 / $49.03
| Professional | | $20.30 | $27.64 | $49.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.07 / $53.01 / $69.44
| Professional | | $46.07 | $53.01 | $69.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.55 / $26.53 / $30.95
| Professional | | $22.55 | $26.53 | $30.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.55 / $27.64 / $60.02
| Professional | | $22.55 | $27.64 | $60.02 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.88 / $33.69 / $61.50
| Professional | | $23.88 | $33.69 | $61.50 |