- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $194.98 / $316.23
| Professional | | $112.20 | $194.98 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $208.93 / $436.52
| Professional | | $208.93 | $208.93 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $346.74 / $354.81
| Professional | | $275.42 | $346.74 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $199.53 / $239.88
| Professional | | $93.33 | $199.53 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $213.80 / $407.38
| Professional | | $134.90 | $213.80 | $407.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $151.36 / $309.03
| Professional | | $104.71 | $151.36 | $309.03 |