- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.01 / $83.31 / $121.88
| Professional | | $67.01 | $83.31 | $121.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.90 / $116.20 / $173.55
| Professional | | $87.90 | $116.20 | $173.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.30 / $128.59 / $130.12
| Professional | | $118.30 | $128.59 | $130.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.31 / $111.91 / $123.37
| Professional | | $79.31 | $111.91 | $123.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $110.02 / $154.04
| Professional | | $95.50 | $110.02 | $154.04 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.59 / $85.03 / $115.03
| Professional | | $74.59 | $85.03 | $115.03 |