- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.80 / $28.84 / $128.72
| Professional | | $22.80 | $28.84 | $128.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.07 / $32.97 / $56.97
| Professional | | $25.07 | $32.97 | $56.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.19 / $32.36 / $38.15
| Professional | | $28.19 | $32.36 | $38.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.91 / $31.66 / $36.93
| Professional | | $26.91 | $31.66 | $36.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.80 / $32.97 / $47.46
| Professional | | $23.80 | $32.97 | $47.46 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.52 / $35.04 / $98.43
| Professional | | $21.52 | $35.04 | $98.43 |