- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.15 / $232.15 / $232.15
| Professional | | $232.15 | $232.15 | $232.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.77 / $51.25 / $193.40
| Professional | | $23.77 | $51.25 | $193.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.60 / $686.60 / $718.95
| Professional | | $686.60 | $686.60 | $718.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.72 / $65.72 / $65.72
| Professional | | $65.72 | $65.72 | $65.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.58 / $200.20 / $699.01
| Professional | | $139.58 | $200.20 | $699.01 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.00 / $299.00 / $299.00
| Professional | | $299.00 | $299.00 | $299.00 |