- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.29 / $37.29 / $38.20
| Professional | | $37.29 | $37.29 | $38.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.46 / $44.94 / $44.94
| Professional | | $21.46 | $44.94 | $44.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.24 / $66.59 / $76.73
| Professional | | $59.24 | $66.59 | $76.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $70.00 / $70.00
| Professional | | $70.00 | $70.00 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.20 / $47.68 / $76.41
| Professional | | $15.20 | $47.68 | $76.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.25 / $39.72 / $41.39
| Professional | | $16.25 | $39.72 | $41.39 |