- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.92 / $107.12 / $183.06
| Professional | | $89.92 | $107.12 | $183.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.25 / $162.11 / $194.54
| Professional | | $128.25 | $162.11 | $194.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.54 / $178.96 / $201.30
| Professional | | $155.54 | $178.96 | $201.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.27 / $142.66 / $168.60
| Professional | | $124.27 | $142.66 | $168.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.56 / $140.07 / $193.10
| Professional | | $105.56 | $140.07 | $193.10 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $123.55 / $161.51
| Professional | | $29.27 | $123.55 | $161.51 |