- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.33 / $67.62 / $105.86
| Professional | | $38.33 | $67.62 | $105.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.11 / $90.83 / $124.33
| Professional | | $66.11 | $90.83 | $124.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.22 / $60.02 / $113.69
| Professional | | $52.22 | $60.02 | $113.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.56 / $69.38 / $100.92
| Professional | | $42.56 | $69.38 | $100.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.78 / $102.40 / $132.51
| Professional | | $85.78 | $102.40 | $132.51 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.15 / $38.15 / $76.14
| Professional | | $38.15 | $38.15 | $76.14 |