- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.12 / $172.72 / $282.51
| Professional | | $154.12 | $172.72 | $282.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.53 / $282.89 / $298.10
| Professional | | $187.53 | $282.89 | $298.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.02 / $287.08 / $390.47
| Professional | | $244.02 | $287.08 | $390.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.88 / $262.33 / $333.87
| Professional | | $167.88 | $262.33 | $333.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.25 / $298.10 / $471.95
| Professional | | $243.25 | $298.10 | $471.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.69 / $206.36 / $341.54
| Professional | | $42.69 | $206.36 | $341.54 |