- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.48 / $140.26 / $199.69
| Professional | | $116.48 | $140.26 | $199.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.06 / $156.04 / $211.85
| Professional | | $130.06 | $156.04 | $211.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.93 / $205.00 / $260.05
| Professional | | $176.93 | $205.00 | $260.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.65 / $186.43 / $237.27
| Professional | | $122.65 | $186.43 | $237.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.87 / $211.85 / $245.84
| Professional | | $172.87 | $211.85 | $245.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.88 / $149.80 / $239.50
| Professional | | $29.88 | $149.80 | $239.50 |