- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.68 / $57.25 / $107.51
| Professional | | $40.68 | $57.25 | $107.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.81 / $83.85 / $100.62
| Professional | | $62.81 | $83.85 | $100.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.81 / $82.55 / $99.36
| Professional | | $69.81 | $82.55 | $99.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.85 / $71.09 / $83.85
| Professional | | $48.85 | $71.09 | $83.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.59 / $83.72 / $104.06
| Professional | | $66.59 | $83.72 | $104.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $57.72 / $86.91
| Professional | | $29.27 | $57.72 | $86.91 |