- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.45 / $75.93 / $108.16
| Professional | | $60.45 | $75.93 | $108.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.02 / $100.35 / $166.12
| Professional | | $71.02 | $100.35 | $166.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.04 / $103.38 / $123.22
| Professional | | $93.04 | $103.38 | $123.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.00 / $670.00 / $670.00
| Professional | | $670.00 | $670.00 | $670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.45 / $111.22 / $150.71
| Professional | | $78.45 | $111.22 | $150.71 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.04 / $58.84 / $80.30
| Professional | | $58.04 | $58.84 | $80.30 |