- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.60 / $87.60 / $140.63
| Professional | | $87.60 | $87.60 | $140.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.69 / $129.05 / $130.75
| Professional | | $106.69 | $129.05 | $130.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.94 / $140.37 / $146.97
| Professional | | $136.94 | $140.37 | $146.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.06 / $125.52 / $146.44
| Professional | | $115.06 | $125.52 | $146.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.69 / $130.75 / $175.58
| Professional | | $106.69 | $130.75 | $175.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.96 / $99.53 / $114.90
| Professional | | $81.96 | $99.53 | $114.90 |