- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.04 / $78.53 / $94.96
| Professional | | $65.04 | $78.53 | $94.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.75 / $75.52 / $110.48
| Professional | | $63.75 | $75.52 | $110.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.00 / $100.00 / $126.56
| Professional | | $90.00 | $100.00 | $126.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.50 / $97.22 / $112.50
| Professional | | $82.50 | $97.22 | $112.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.83 / $95.45 / $146.72
| Professional | | $74.83 | $95.45 | $146.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.91 / $81.25 / $139.62
| Professional | | $66.91 | $81.25 | $139.62 |