- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.91 / $216.91 / $216.91
| Professional | | $216.91 | $216.91 | $216.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.19 / $238.19 / $238.19
| Professional | | $238.19 | $238.19 | $238.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.97 / $240.97 / $240.97
| Professional | | $240.97 | $240.97 | $240.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.03 / $255.20 / $328.58
| Professional | | $205.03 | $255.20 | $328.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.44 / $175.95 / $200.52
| Professional | | $170.44 | $175.95 | $200.52 |