- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.56 / $74.56 / $93.71
| Professional | | $74.56 | $74.56 | $93.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.20 / $75.20 / $75.20
| Professional | | $75.20 | $75.20 | $75.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.76 / $140.79 / $165.63
| Professional | | $99.76 | $140.79 | $165.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.18 / $72.19 / $84.22
| Professional | | $66.18 | $72.19 | $84.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.20 / $75.20 / $102.75
| Professional | | $75.20 | $75.20 | $102.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.98 / $97.42 / $146.46
| Professional | | $72.98 | $97.42 | $146.46 |