- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.10 / $49.03 / $71.18
| Professional | | $17.10 | $49.03 | $71.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.72 / $80.39 / $125.60
| Professional | | $20.72 | $80.39 | $125.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.10 / $89.81 / $2,000.00
| Professional | | $29.10 | $89.81 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.92 / $85.40 / $117.22
| Professional | | $18.92 | $85.40 | $117.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.04 / $91.68 / $114.24
| Professional | | $62.04 | $91.68 | $114.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.39 / $68.20 / $90.62
| Professional | | $16.39 | $68.20 | $90.62 |