- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.00 / $196.92 / $385.00
| Professional | | $128.00 | $196.92 | $385.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.37 / $172.37 / $172.37
| Professional | | $172.37 | $172.37 | $172.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.21 / $166.21 / $166.21
| Professional | | $166.21 | $166.21 | $166.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.19 / $149.63 / $230.85
| Professional | | $137.19 | $149.63 | $230.85 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.49 / $132.72 / $175.33
| Professional | | $40.49 | $132.72 | $175.33 |