- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.42 / $92.34 / $220.40
| Professional | | $73.42 | $92.34 | $220.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.66 / $162.59 / $195.11
| Professional | | $132.66 | $162.59 | $195.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.35 / $149.28 / $178.20
| Professional | | $139.35 | $149.28 | $178.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.08 / $156.08 / $182.10
| Professional | | $143.08 | $156.08 | $182.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.87 / $162.59 / $264.02
| Professional | | $75.87 | $162.59 | $264.02 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.68 / $157.46 / $171.27
| Professional | | $96.68 | $157.46 | $171.27 |