- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $208.93 / $338.84
| Professional | | $134.90 | $208.93 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $281.84 / $724.44
| Professional | | $154.88 | $281.84 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $281.84 / $371.54
| Professional | | $239.88 | $281.84 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $316.23 / $436.52
| Professional | | $151.36 | $316.23 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $229.09 / $354.81
| Professional | | $144.54 | $229.09 | $354.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $194.98 / $380.19
| Professional | | $47.86 | $194.98 | $380.19 |