- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $37.64 / $4,500.00
| Professional | | $33.88 | $37.64 | $4,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $33.88 / $43.51
| Professional | | $33.88 | $33.88 | $43.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.47 / $51.47 / $51.47
| Professional | | $51.47 | $51.47 | $51.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $40.65 / $50.82
| Professional | | $33.88 | $40.65 | $50.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $33.88 / $50.82
| Professional | | $33.88 | $33.88 | $50.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.25 / $42.65 / $48.59
| Professional | | $34.25 | $42.65 | $48.59 |