- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.62 / $144.76 / $242.21
| Professional | | $74.62 | $144.76 | $242.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.71 / $213.24 / $394.74
| Professional | | $95.71 | $213.24 | $394.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.56 / $161.27 / $321.95
| Professional | | $133.56 | $161.27 | $321.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.65 / $237.09 / $325.42
| Professional | | $87.65 | $237.09 | $325.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.18 / $284.27 / $367.44
| Professional | | $179.18 | $284.27 | $367.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.34 / $1,350.00 / $3,663.00
| Professional | | $107.34 | $1,350.00 | $3,663.00 |