- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.03 / $84.68 / $101.24
| Professional | | $61.03 | $84.68 | $101.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.41 / $81.92 / $124.28
| Professional | | $60.41 | $81.92 | $124.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.21 / $109.34 / $128.63
| Professional | | $104.21 | $109.34 | $128.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.36 / $109.36 / $139.19
| Professional | | $109.36 | $109.36 | $139.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.29 / $101.41 / $127.65
| Professional | | $47.29 | $101.41 | $127.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.44 / $76.38 / $114.62
| Professional | | $33.44 | $76.38 | $114.62 |