- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.50 / $211.34 / $442.46
| Professional | | $163.50 | $211.34 | $442.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.20 / $232.20 / $232.20
| Professional | | $232.20 | $232.20 | $232.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.77 / $223.77 / $223.77
| Professional | | $223.77 | $223.77 | $223.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.35 / $248.63 / $310.98
| Professional | | $193.35 | $248.63 | $310.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.08 / $176.56 / $217.69
| Professional | | $150.08 | $176.56 | $217.69 |