- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.54 / $102.42 / $178.70
| Professional | | $78.54 | $102.42 | $178.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.91 / $138.10 / $172.00
| Professional | | $94.91 | $138.10 | $172.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.48 / $93.20 / $213.12
| Professional | | $72.48 | $93.20 | $213.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $165.12 / $192.64
| Professional | | $151.36 | $165.12 | $192.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.98 / $172.00 / $226.24
| Professional | | $124.98 | $172.00 | $226.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.39 / $137.88 / $183.15
| Professional | | $103.39 | $137.88 | $183.15 |