- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.75 / $84.92 / $114.87
| Professional | | $72.75 | $84.92 | $114.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.00 / $98.00 / $145.13
| Professional | | $71.00 | $98.00 | $145.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.25 / $112.30 / $129.15
| Professional | | $107.25 | $112.30 | $129.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.68 / $98.32 / $109.85
| Professional | | $69.68 | $98.32 | $109.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.53 / $98.56 / $157.97
| Professional | | $88.53 | $98.56 | $157.97 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.84 / $98.04 / $123.44
| Professional | | $71.84 | $98.04 | $123.44 |