- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.50 / $70.14 / $87.61
| Professional | | $57.50 | $70.14 | $87.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.48 / $123.48 / $152.52
| Professional | | $123.48 | $123.48 | $152.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.89 / $96.22 / $118.30
| Professional | | $91.89 | $96.22 | $118.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.18 / $97.42 / $101.48
| Professional | | $81.18 | $97.42 | $101.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.92 / $101.48 / $116.19
| Professional | | $72.92 | $101.48 | $116.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.72 / $64.02 / $87.37
| Professional | | $52.72 | $64.02 | $87.37 |