- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.12 / $57.54 / $93.33
| Professional | | $25.12 | $57.54 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.90 / $85.11 / $151.36
| Professional | | $30.90 | $85.11 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $104.71 / $1,995.26
| Professional | | $43.65 | $104.71 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.30 / $120.23 / $154.88
| Professional | | $26.30 | $120.23 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.70 / $69.18 / $112.20
| Professional | | $25.70 | $69.18 | $112.20 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.99 / $93.33 / $147.91
| Professional | | $23.99 | $93.33 | $147.91 |