- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.28 / $150.76 / $216.89
| Professional | | $121.28 | $150.76 | $216.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.21 / $161.30 / $299.94
| Professional | | $129.21 | $161.30 | $299.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.86 / $173.13 / $199.10
| Professional | | $146.86 | $173.13 | $199.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.62 / $154.85 / $180.66
| Professional | | $131.62 | $154.85 | $180.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.77 / $161.30 / $251.76
| Professional | | $119.77 | $161.30 | $251.76 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.13 / $182.57 / $390.24
| Professional | | $136.13 | $182.57 | $390.24 |