- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $263.03 / $380.19
| Professional | | $181.97 | $263.03 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $363.08 / $436.52
| Professional | | $275.42 | $363.08 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $446.68 / $2,570.40
| Professional | | $128.82 | $446.68 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $323.59 / $407.38
| Professional | | $302.00 | $323.59 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $331.13 / $354.81
| Professional | | $263.03 | $331.13 | $354.81 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.51 / $269.15 / $407.38
| Professional | | $29.51 | $269.15 | $407.38 |