- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $75.86 / $114.82
| Professional | | $61.66 | $75.86 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $83.18 / $117.49
| Professional | | $63.10 | $83.18 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $138.04 / $173.78
| Professional | | $123.03 | $138.04 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $89.13 / $93.33
| Professional | | $83.18 | $89.13 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $93.33 / $128.82
| Professional | | $70.79 | $93.33 | $128.82 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $53.70 / $128.82
| Professional | | $38.90 | $53.70 | $128.82 |