- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.30 / $140.71 / $224.77
| Professional | | $102.30 | $140.71 | $224.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.66 / $262.17 / $327.96
| Professional | | $153.66 | $262.17 | $327.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.96 / $253.01 / $386.30
| Professional | | $213.96 | $253.01 | $386.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.65 / $288.61 / $367.32
| Professional | | $151.65 | $288.61 | $367.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.62 / $327.96 / $403.32
| Professional | | $267.62 | $327.96 | $403.32 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.54 / $241.95 / $4,597.00
| Professional | | $45.54 | $241.95 | $4,597.00 |