- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.94 / $118.40 / $242.26
| Professional | | $46.94 | $118.40 | $242.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.25 / $126.07 / $216.75
| Professional | | $46.25 | $126.07 | $216.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.28 / $178.22 / $212.75
| Professional | | $155.28 | $178.22 | $212.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.94 / $173.40 / $202.30
| Professional | | $158.94 | $173.40 | $202.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.88 / $180.63 / $269.33
| Professional | | $124.88 | $180.63 | $269.33 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.60 / $55.41 / $204.88
| Professional | | $40.60 | $55.41 | $204.88 |