- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.20 / $106.88 / $133.44
| Professional | | $78.20 | $106.88 | $133.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.30 / $175.30 / $218.37
| Professional | | $175.30 | $175.30 | $218.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.78 / $153.69 / $188.95
| Professional | | $146.78 | $153.69 | $188.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $155.38 / $161.85
| Professional | | $129.47 | $155.38 | $161.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.09 / $161.85 / $166.76
| Professional | | $95.09 | $161.85 | $166.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.42 / $91.58 / $124.98
| Professional | | $75.42 | $91.58 | $124.98 |