- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.81 / $148.81 / $148.81
| Professional | | $148.81 | $148.81 | $148.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.43 / $138.43 / $138.43
| Professional | | $138.43 | $138.43 | $138.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.16 / $169.69 / $187.71
| Professional | | $150.16 | $169.69 | $187.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.81 / $132.88 / $155.04
| Professional | | $121.81 | $132.88 | $155.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.95 / $138.43 / $178.17
| Professional | | $112.95 | $138.43 | $178.17 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.42 / $107.37 / $189.27
| Professional | | $88.42 | $107.37 | $189.27 |