- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.31 / $81.88 / $356.94
| Professional | | $65.31 | $81.88 | $356.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.42 / $86.06 / $157.71
| Professional | | $58.42 | $86.06 | $157.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.15 / $92.30 / $106.15
| Professional | | $82.15 | $92.30 | $106.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.44 / $84.48 / $91.52
| Professional | | $77.44 | $84.48 | $91.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.14 / $88.00 / $117.03
| Professional | | $73.14 | $88.00 | $117.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.61 / $66.31 / $90.50
| Professional | | $54.61 | $66.31 | $90.50 |