- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.46 / $142.63 / $222.92
| Professional | | $127.46 | $142.63 | $222.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.49 / $136.86 / $200.58
| Professional | | $104.49 | $136.86 | $200.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.16 / $167.38 / $199.81
| Professional | | $148.16 | $167.38 | $199.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.19 / $157.87 / $184.18
| Professional | | $134.19 | $157.87 | $184.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.71 / $160.04 / $240.99
| Professional | | $133.71 | $160.04 | $240.99 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.23 / $156.75 / $310.42
| Professional | | $115.23 | $156.75 | $310.42 |