- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.15 / $74.98 / $90.66
| Professional | | $38.15 | $74.98 | $90.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.45 / $72.84 / $111.26
| Professional | | $35.45 | $72.84 | $111.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.57 / $97.12 / $114.26
| Professional | | $92.57 | $97.12 | $114.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.91 / $97.91 / $124.61
| Professional | | $97.91 | $97.91 | $124.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.64 / $96.13 / $111.26
| Professional | | $36.64 | $96.13 | $111.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.39 / $55.82 / $67.78
| Professional | | $27.39 | $55.82 | $67.78 |