- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.18 / $56.23 / $107.15
| Professional | | $28.18 | $56.23 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.05 / $36.31 / $43.65
| Professional | | $19.05 | $36.31 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $112.20 / $131.83
| Professional | | $79.43 | $112.20 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $43.65 / $50.12
| Professional | | $39.81 | $43.65 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.39 / $40.74 / $60.26
| Professional | | $22.39 | $40.74 | $60.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.69 / $74.13 / $117.49
| Professional | | $41.69 | $74.13 | $117.49 |