- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.65 / $164.64 / $254.45
| Professional | | $141.65 | $164.64 | $254.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.86 / $198.26 / $237.92
| Professional | | $157.86 | $198.26 | $237.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.53 / $227.68 / $261.83
| Professional | | $193.53 | $227.68 | $261.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.99 / $174.47 / $198.26
| Professional | | $142.99 | $174.47 | $198.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.75 / $198.26 / $252.71
| Professional | | $156.75 | $198.26 | $252.71 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.58 / $1,402.00 / $3,725.00
| Professional | | $141.58 | $1,402.00 | $3,725.00 |