- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.70 / $58.02 / $81.53
| Professional | | $23.70 | $58.02 | $81.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.26 / $92.00 / $135.30
| Professional | | $30.26 | $92.00 | $135.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.27 / $101.53 / $2,000.00
| Professional | | $42.27 | $101.53 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.68 / $92.00 / $126.28
| Professional | | $27.68 | $92.00 | $126.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.61 / $101.80 / $129.12
| Professional | | $71.61 | $101.80 | $129.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.82 / $90.50 / $102.44
| Professional | | $23.82 | $90.50 | $102.44 |