- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.37 / $70.06 / $95.26
| Professional | | $69.37 | $70.06 | $95.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.37 / $69.37 / $86.37
| Professional | | $69.37 | $69.37 | $86.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.09 / $105.09 / $105.09
| Professional | | $105.09 | $105.09 | $105.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.37 / $83.24 / $104.05
| Professional | | $69.37 | $83.24 | $104.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.90 / $73.42 / $104.06
| Professional | | $65.90 | $73.42 | $104.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.40 / $69.37 / $92.85
| Professional | | $36.40 | $69.37 | $92.85 |