- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.20 / $50.38 / $76.04
| Professional | | $37.20 | $50.38 | $76.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.27 / $94.73 / $120.10
| Professional | | $57.27 | $94.73 | $120.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.45 / $85.77 / $135.65
| Professional | | $74.45 | $85.77 | $135.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.32 / $105.69 / $134.51
| Professional | | $51.32 | $105.69 | $134.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.00 / $120.10 / $142.31
| Professional | | $98.00 | $120.10 | $142.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.54 / $1,402.00 / $3,725.00
| Professional | | $63.54 | $1,402.00 | $3,725.00 |