- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.79 / $73.79 / $112.27
| Professional | | $73.79 | $73.79 | $112.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.01 / $100.93 / $102.95
| Professional | | $84.01 | $100.93 | $102.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.60 / $120.00 / $123.01
| Professional | | $114.60 | $120.00 | $123.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.60 / $98.83 / $115.30
| Professional | | $90.60 | $98.83 | $115.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.01 / $102.95 / $148.65
| Professional | | $84.01 | $102.95 | $148.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.68 / $76.11 / $112.69
| Professional | | $62.68 | $76.11 | $112.69 |