- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.30 / $235.00 / $400.00
| Professional | | $43.30 | $235.00 | $400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.15 / $269.89 / $389.96
| Professional | | $191.15 | $269.89 | $389.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.72 / $381.67 / $465.88
| Professional | | $331.72 | $381.67 | $465.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.17 / $311.95 / $363.96
| Professional | | $265.17 | $311.95 | $363.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.35 / $233.97 / $324.95
| Professional | | $40.35 | $233.97 | $324.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.10 / $49.88 / $517.96
| Professional | | $30.10 | $49.88 | $517.96 |