- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.54 / $256.22 / $351.42
| Professional | | $187.54 | $256.22 | $351.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.00 / $375.00 / $719.06
| Professional | | $216.00 | $375.00 | $719.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.49 / $378.89 / $506.55
| Professional | | $318.49 | $378.89 | $506.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.84 / $324.11 / $444.85
| Professional | | $224.84 | $324.11 | $444.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.02 / $397.19 / $535.00
| Professional | | $291.02 | $397.19 | $535.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.39 / $275.35 / $439.62
| Professional | | $55.39 | $275.35 | $439.62 |