- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.15 / $124.46 / $124.46
| Professional | | $122.15 | $124.46 | $124.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.58 / $151.21 / $151.21
| Professional | | $119.58 | $151.21 | $151.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.87 / $35.18 / $201.29
| Professional | | $27.87 | $35.18 | $201.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.07 / $145.16 / $169.36
| Professional | | $133.07 | $145.16 | $169.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.39 / $151.21 / $195.65
| Professional | | $123.39 | $151.21 | $195.65 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.50 / $108.93 / $211.93
| Professional | | $20.50 | $108.93 | $211.93 |