- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.06 / $85.22 / $274.99
| Professional | | $73.06 | $85.22 | $274.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.99 / $317.10 / $405.93
| Professional | | $108.99 | $317.10 | $405.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $166.81 / $505.18
| Professional | | $141.06 | $166.81 | $505.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.34 / $357.21 / $454.64
| Professional | | $94.34 | $357.21 | $454.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.23 / $405.93 / $503.67
| Professional | | $331.23 | $405.93 | $503.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $104.38 / $383.19
| Professional | | $29.27 | $104.38 | $383.19 |