- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.46 / $37.47 / $337.50
| Professional | | $22.46 | $37.47 | $337.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.29 / $41.13 / $69.68
| Professional | | $26.29 | $41.13 | $69.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.93 / $42.61 / $49.00
| Professional | | $37.93 | $42.61 | $49.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.00 / $670.00 / $670.00
| Professional | | $670.00 | $670.00 | $670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.87 / $43.76 / $58.16
| Professional | | $30.87 | $43.76 | $58.16 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.44 / $39.49 / $51.96
| Professional | | $29.44 | $39.49 | $51.96 |