- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.72 / $122.22 / $139.68
| Professional | | $87.72 | $122.22 | $139.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.83 / $111.23 / $159.55
| Professional | | $61.83 | $111.23 | $159.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.44 / $164.54 / $189.22
| Professional | | $146.44 | $164.54 | $189.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.16 / $137.94 / $165.93
| Professional | | $101.16 | $137.94 | $165.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.39 / $137.85 / $162.65
| Professional | | $106.39 | $137.85 | $162.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.21 / $117.15 / $170.90
| Professional | | $85.21 | $117.15 | $170.90 |