- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $229.09 / $245.47
| Professional | | $120.23 | $229.09 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $181.97
| Professional | | $104.71 | $104.71 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $257.04 / $263.03
| Professional | | $223.87 | $257.04 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $181.97 / $208.93
| Professional | | $165.96 | $181.97 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $181.97 / $288.40
| Professional | | $123.03 | $181.97 | $288.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $263.03 / $371.54
| Professional | | $169.82 | $263.03 | $371.54 |