- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.28 / $296.68 / $368.88
| Professional | | $201.28 | $296.68 | $368.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.22 / $376.50 / $393.41
| Professional | | $262.22 | $376.50 | $393.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.14 / $401.03 / $514.33
| Professional | | $339.14 | $401.03 | $514.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.74 / $346.20 / $440.62
| Professional | | $231.74 | $346.20 | $440.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.02 / $393.41 / $599.61
| Professional | | $321.02 | $393.41 | $599.61 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.52 / $1,402.00 / $3,725.00
| Professional | | $263.52 | $1,402.00 | $3,725.00 |