- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.44 / $84.29 / $93.30
| Professional | | $79.44 | $84.29 | $93.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.71 / $117.43 / $368.32
| Professional | | $92.71 | $117.43 | $368.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.16 / $160.88 / $181.11
| Professional | | $140.16 | $160.88 | $181.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.22 / $103.46 / $120.71
| Professional | | $86.22 | $103.46 | $120.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.87 / $107.78 / $155.47
| Professional | | $79.87 | $107.78 | $155.47 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.81 / $78.70 / $107.40
| Professional | | $64.81 | $78.70 | $107.40 |