- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $97.01
| Professional | | $60.00 | $60.00 | $97.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.94 / $71.04 / $128.49
| Professional | | $57.94 | $71.04 | $128.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $95.95 / $106.61
| Professional | | $30.00 | $95.95 | $106.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.01 / $81.83 / $102.79
| Professional | | $75.01 | $81.83 | $102.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.50 / $68.05 / $107.08
| Professional | | $46.50 | $68.05 | $107.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.50 / $51.30 / $87.29
| Professional | | $31.50 | $51.30 | $87.29 |