- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.95 / $100.31 / $158.41
| Professional | | $80.95 | $100.31 | $158.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.09 / $130.35 / $211.86
| Professional | | $91.09 | $130.35 | $211.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.31 / $133.68 / $156.54
| Professional | | $120.31 | $133.68 | $156.54 |
- 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
- $100.62 / $143.03 / $193.50
| Professional | | $100.62 | $143.03 | $193.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.59 / $76.01 / $103.73
| Professional | | $62.59 | $76.01 | $103.73 |