- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.70 / $222.70 / $367.79
| Professional | | $222.70 | $222.70 | $367.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.03 / $410.91 / $493.10
| Professional | | $355.03 | $410.91 | $493.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.01 / $399.33 / $491.82
| Professional | | $323.01 | $399.33 | $491.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.73 / $328.73 / $410.91
| Professional | | $228.73 | $328.73 | $410.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.70 / $401.06 / $517.08
| Professional | | $282.70 | $401.06 | $517.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.81 / $275.64 / $477.91
| Professional | | $57.81 | $275.64 | $477.91 |