- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.85 / $26.11 / $107.00
| Professional | | $21.85 | $26.11 | $107.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.23 / $34.60 / $41.52
| Professional | | $28.23 | $34.60 | $41.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.73 / $31.32 / $37.39
| Professional | | $28.73 | $31.32 | $37.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.45 / $33.22 / $38.75
| Professional | | $30.45 | $33.22 | $38.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.63 / $34.60 / $50.50
| Professional | | $25.63 | $34.60 | $50.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.73 / $31.83 / $34.61
| Professional | | $23.73 | $31.83 | $34.61 |