- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.38 / $282.93 / $439.35
| Professional | | $178.38 | $282.93 | $439.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.49 / $335.75 / $402.90
| Professional | | $265.49 | $335.75 | $402.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.79 / $303.66 / $426.48
| Professional | | $256.79 | $303.66 | $426.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.95 / $284.72 / $335.75
| Professional | | $178.95 | $284.72 | $335.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.04 / $335.75 / $433.88
| Professional | | $263.04 | $335.75 | $433.88 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.63 / $205.44 / $370.13
| Professional | | $46.63 | $205.44 | $370.13 |