- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.48 / $94.57 / $352.18
| Professional | | $69.48 | $94.57 | $352.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.14 / $93.03 / $160.88
| Professional | | $61.14 | $93.03 | $160.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.43 / $99.53 / $114.46
| Professional | | $84.43 | $99.53 | $114.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.91 / $89.30 / $104.19
| Professional | | $75.91 | $89.30 | $104.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.68 / $93.03 / $134.57
| Professional | | $60.68 | $93.03 | $134.57 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.14 / $161.04 / $247.63
| Professional | | $74.14 | $161.04 | $247.63 |