- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.57 / $156.00 / $227.83
| Professional | | $109.57 | $156.00 | $227.83 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $234.12 / $234.12 / $234.12
| Professional | 25 | $234.12 | $234.12 | $234.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $173.56 / $260.12
| Professional | | $70.00 | $173.56 | $260.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.22 / $212.30 / $244.15
| Professional | | $159.22 | $212.30 | $244.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.47 / $197.96 / $231.41
| Professional | | $148.47 | $197.96 | $231.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.16 / $196.55 / $400.00
| Professional | | $144.16 | $196.55 | $400.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.18 / $176.05 / $238.19
| Professional | | $152.18 | $176.05 | $238.19 |