- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.68 / $44.86 / $109.20
| Professional | | $28.68 | $44.86 | $109.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.32 / $88.52 / $168.03
| Professional | | $29.32 | $88.52 | $168.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.53 / $111.94 / $131.94
| Professional | | $97.53 | $111.94 | $131.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.78 / $88.35 / $123.69
| Professional | | $31.78 | $88.35 | $123.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.33 / $108.59 / $140.84
| Professional | | $76.33 | $108.59 | $140.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.09 / $109.71 / $183.88
| Professional | | $31.09 | $109.71 | $183.88 |