- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.72 / $167.72 / $215.47
| Professional | | $167.72 | $167.72 | $215.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.35 / $292.33 / $350.81
| Professional | | $229.35 | $292.33 | $350.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.33 / $299.82 / $368.57
| Professional | | $257.33 | $299.82 | $368.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.95 / $247.90 / $292.33
| Professional | | $177.95 | $247.90 | $292.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.73 / $292.33 / $369.54
| Professional | | $226.73 | $292.33 | $369.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.29 / $214.08 / $322.38
| Professional | | $40.29 | $214.08 | $322.38 |