- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.05 / $87.86 / $100.60
| Professional | | $80.05 | $87.86 | $100.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.36 / $112.81 / $185.68
| Professional | | $86.36 | $112.81 | $185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.47 / $124.50 / $146.75
| Professional | | $108.47 | $124.50 | $146.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.32 / $98.86 / $115.33
| Professional | | $87.32 | $98.86 | $115.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.90 / $98.94 / $137.86
| Professional | | $79.90 | $98.94 | $137.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.62 / $91.51 / $117.68
| Professional | | $62.62 | $91.51 | $117.68 |