- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.94 / $188.99 / $188.99
| Professional | | $153.94 | $188.99 | $188.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.55 / $244.06 / $244.06
| Professional | | $196.55 | $244.06 | $244.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.29 / $310.99 / $2,342.00
| Professional | | $270.29 | $310.99 | $2,342.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.78 / $234.30 / $273.35
| Professional | | $214.78 | $234.30 | $273.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.16 / $244.06 / $314.01
| Professional | | $199.16 | $244.06 | $314.01 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.77 / $244.48 / $278.14
| Professional | | $34.77 | $244.48 | $278.14 |