- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.44 / $206.02 / $225.10
| Professional | | $149.44 | $206.02 | $225.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.60 / $104.60 / $247.75
| Professional | | $104.60 | $104.60 | $247.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.00 / $141.36 / $141.36
| Professional | | $135.00 | $141.36 | $141.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.32 / $315.32 / $315.32
| Professional | | $315.32 | $315.32 | $315.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.13 / $138.94 / $280.92
| Professional | | $85.13 | $138.94 | $280.92 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.65 / $197.22 / $214.38
| Professional | | $187.65 | $197.22 | $214.38 |