- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.68 / $143.62 / $190.93
| Professional | | $109.68 | $143.62 | $190.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.01 / $198.97 / $246.41
| Professional | | $146.01 | $198.97 | $246.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.10 / $243.04 / $279.50
| Professional | | $232.10 | $243.04 | $279.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.36 / $165.20 / $194.68
| Professional | | $120.36 | $165.20 | $194.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.47 / $176.47 / $273.08
| Professional | | $165.47 | $176.47 | $273.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.09 / $110.09 / $151.11
| Professional | | $110.09 | $110.09 | $151.11 |