- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.55 / $52.30 / $7,084.80
| Professional | | $47.55 | $52.30 | $7,084.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.38 / $47.55 / $47.55
| Professional | | $35.38 | $47.55 | $47.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.65 / $50.65 / $50.65
| Professional | | $50.65 | $50.65 | $50.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.55 / $57.06 / $71.31
| Professional | | $47.55 | $57.06 | $71.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.46 / $47.55 / $71.33
| Professional | | $37.46 | $47.55 | $71.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.33 / $43.28 / $117.87
| Professional | | $24.33 | $43.28 | $117.87 |