- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.21 / $184.73 / $450.68
| Professional | | $144.21 | $184.73 | $450.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.44 / $174.44 / $174.44
| Professional | | $174.44 | $174.44 | $174.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.21 / $168.21 / $168.21
| Professional | | $168.21 | $168.21 | $168.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.31 / $213.07 / $248.58
| Professional | | $195.31 | $213.07 | $248.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.90 / $201.96 / $233.63
| Professional | | $186.90 | $201.96 | $233.63 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.73 / $140.86 / $163.54
| Professional | | $119.73 | $140.86 | $163.54 |