- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.09 / $105.37 / $142.90
| Professional | | $93.09 | $105.37 | $142.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.54 / $133.44 / $226.20
| Professional | | $99.54 | $133.44 | $226.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.91 / $127.02 / $152.75
| Professional | | $112.91 | $127.02 | $152.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.89 / $128.10 / $149.44
| Professional | | $108.89 | $128.10 | $149.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.17 / $133.44 / $177.75
| Professional | | $95.17 | $133.44 | $177.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.83 / $144.41 / $242.70
| Professional | | $105.83 | $144.41 | $242.70 |