- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.54 / $227.07 / $401.69
| Professional | | $136.54 | $227.07 | $401.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.50 / $267.89 / $304.95
| Professional | | $167.50 | $267.89 | $304.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.44 / $280.77 / $392.21
| Professional | | $237.44 | $280.77 | $392.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.33 / $268.36 / $341.54
| Professional | | $165.33 | $268.36 | $341.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.84 / $304.95 / $388.26
| Professional | | $248.84 | $304.95 | $388.26 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.55 / $234.93 / $344.88
| Professional | | $134.55 | $234.93 | $344.88 |