- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.56 / $67.56 / $75.26
| Professional | | $67.56 | $67.56 | $75.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.46 / $49.60 / $90.32
| Professional | | $38.46 | $49.60 | $90.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $66.51 / $73.90
| Professional | | $30.00 | $66.51 | $73.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.87 / $54.41 / $72.25
| Professional | | $49.87 | $54.41 | $72.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.50 / $51.40 / $75.26
| Professional | | $34.50 | $51.40 | $75.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.50 / $45.00 / $57.06
| Professional | | $31.50 | $45.00 | $57.06 |