- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $234.42 / $354.81
| Professional | | $158.49 | $234.42 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $275.42 / $380.19
| Professional | | $204.17 | $275.42 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $346.74 / $2,137.96
| Professional | | $275.42 | $346.74 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $302.00 / $371.54
| Professional | | $169.82 | $302.00 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $269.15 / $363.08
| Professional | | $134.90 | $269.15 | $363.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $223.87 / $371.54
| Professional | | $46.77 | $223.87 | $371.54 |