- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.05 / $237.62 / $267.20
| Professional | | $116.05 | $237.62 | $267.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.24 / $172.46 / $314.50
| Professional | | $128.24 | $172.46 | $314.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.85 / $570.99 / $714.86
| Professional | | $45.85 | $570.99 | $714.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.72 / $165.56 / $193.16
| Professional | | $140.72 | $165.56 | $193.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.46 / $172.46 / $391.86
| Professional | | $136.46 | $172.46 | $391.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.21 / $169.53 / $386.52
| Professional | | $116.21 | $169.53 | $386.52 |