- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.25 / $203.39 / $321.83
| Professional | | $180.25 | $203.39 | $321.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.02 / $264.35 / $270.20
| Professional | | $237.02 | $264.35 | $270.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.47 / $276.63 / $325.80
| Professional | | $246.47 | $276.63 | $325.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.04 / $242.22 / $282.58
| Professional | | $222.04 | $242.22 | $282.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.44 / $257.89 / $337.64
| Professional | | $210.44 | $257.89 | $337.64 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.72 / $186.67 / $254.75
| Professional | | $153.72 | $186.67 | $254.75 |