- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.38 / $123.34 / $126.48
| Professional | | $75.38 | $123.34 | $126.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.15 / $141.16 / $173.00
| Professional | | $101.15 | $141.16 | $173.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.96 / $159.94 / $185.23
| Professional | | $143.96 | $159.94 | $185.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.40 / $152.24 / $173.00
| Professional | | $138.40 | $152.24 | $173.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.68 / $166.03 / $183.56
| Professional | | $130.68 | $166.03 | $183.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.30 / $164.48 / $398.35
| Professional | | $100.30 | $164.48 | $398.35 |