- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.25 / $252.65 / $359.30
| Professional | | $128.25 | $252.65 | $359.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.76 / $254.61 / $435.08
| Professional | | $207.76 | $254.61 | $435.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.70 / $310.41 / $357.82
| Professional | | $274.70 | $310.41 | $357.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.48 / $203.69 / $254.61
| Professional | | $114.48 | $203.69 | $254.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.76 / $290.93 / $610.94
| Professional | | $207.76 | $290.93 | $610.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.18 / $151.99 / $305.52
| Professional | | $104.18 | $151.99 | $305.52 |