- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.27 / $112.72 / $201.73
| Professional | | $78.27 | $112.72 | $201.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.18 / $128.77 / $185.27
| Professional | | $90.18 | $128.77 | $185.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.13 / $150.16 / $177.49
| Professional | | $135.13 | $150.16 | $177.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.94 / $176.00 / $670.00
| Professional | | $131.94 | $176.00 | $670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.31 / $145.83 / $207.41
| Professional | | $102.31 | $145.83 | $207.41 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.34 / $137.94 / $164.35
| Professional | | $96.34 | $137.94 | $164.35 |