- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.95 / $91.93 / $119.06
| Professional | | $68.95 | $91.93 | $119.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $90.83 / $162.31
| Professional | | $70.00 | $90.83 | $162.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.38 / $176.31 / $202.76
| Professional | | $168.38 | $176.31 | $202.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.94 / $105.28 / $123.11
| Professional | | $76.94 | $105.28 | $123.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.64 / $126.11 / $171.95
| Professional | | $104.64 | $126.11 | $171.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.29 / $94.42 / $127.74
| Professional | | $78.29 | $94.42 | $127.74 |