- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.43 / $170.18 / $256.49
| Professional | | $112.43 | $170.18 | $256.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.21 / $253.84 / $525.91
| Professional | | $141.21 | $253.84 | $525.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.31 / $239.49 / $349.02
| Professional | | $201.31 | $239.49 | $349.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.84 / $269.85 / $370.38
| Professional | | $143.84 | $269.85 | $370.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.85 / $330.70 / $425.12
| Professional | | $212.85 | $330.70 | $425.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.98 / $175.41 / $364.93
| Professional | | $45.98 | $175.41 | $364.93 |