- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.29 / $112.01 / $378.00
| Professional | | $23.29 | $112.01 | $378.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.95 / $142.13 / $226.49
| Professional | | $105.95 | $142.13 | $226.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.58 / $131.68 / $160.69
| Professional | | $113.58 | $131.68 | $160.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.07 / $136.44 / $159.18
| Professional | | $125.07 | $136.44 | $159.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.59 / $136.24 / $169.59
| Professional | | $107.59 | $136.24 | $169.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.69 / $101.18 / $127.09
| Professional | | $76.69 | $101.18 | $127.09 |