- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $309.03 / $524.81
| Professional | | $218.78 | $309.03 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $114.82 / $162.18
| Professional | | $81.28 | $114.82 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.54 / $30.20 / $30.20
| Professional | | $27.54 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.02 / $95.50 / $660.69
| Professional | | $38.02 | $95.50 | $660.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.22 / $27.54 / $30.90
| Professional | | $16.22 | $27.54 | $30.90 |