- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.80 / $150.88 / $152.46
| Professional | | $130.80 | $150.88 | $152.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.60 / $247.63 / $297.14
| Professional | | $186.60 | $247.63 | $297.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.14 / $276.02 / $317.42
| Professional | | $240.14 | $276.02 | $317.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.48 / $217.91 / $247.63
| Professional | | $179.48 | $217.91 | $247.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $242.45 / $298.16
| Professional | | $181.97 | $242.45 | $298.16 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.85 / $179.48 / $254.80
| Professional | | $31.85 | $179.48 | $254.80 |