- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.00 / $198.75 / $229.75
| Professional | | $159.00 | $198.75 | $229.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.01 / $377.46 / $452.96
| Professional | | $308.01 | $377.46 | $452.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.74 / $355.62 / $475.39
| Professional | | $300.74 | $355.62 | $475.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.92 / $301.97 / $377.46
| Professional | | $209.92 | $301.97 | $377.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.97 / $377.46 / $751.58
| Professional | | $305.97 | $377.46 | $751.58 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.76 / $222.54 / $359.10
| Professional | | $51.76 | $222.54 | $359.10 |