- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.39 / $104.66 / $180.56
| Professional | | $78.39 | $104.66 | $180.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.45 / $130.10 / $159.44
| Professional | | $122.45 | $130.10 | $159.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.77 / $90.91 / $170.47
| Professional | | $68.77 | $90.91 | $170.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.31 / $153.06 / $178.57
| Professional | | $140.31 | $153.06 | $178.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.10 / $159.44 / $224.25
| Professional | | $130.10 | $159.44 | $224.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.87 / $139.24 / $193.12
| Professional | | $108.87 | $139.24 | $193.12 |