- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.84 / $106.93 / $147.71
| Professional | | $86.84 | $106.93 | $147.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.98 / $131.57 / $242.27
| Professional | | $107.98 | $131.57 | $242.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.33 / $154.29 / $182.06
| Professional | | $137.33 | $154.29 | $182.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.98 / $127.03 / $148.19
| Professional | | $107.98 | $127.03 | $148.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.65 / $131.36 / $173.64
| Professional | | $97.65 | $131.36 | $173.64 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.67 / $120.23 / $168.71
| Professional | | $17.67 | $120.23 | $168.71 |