- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.03 / $166.47 / $278.77
| Professional | | $85.03 | $166.47 | $278.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.89 / $89.89 / $89.89
| Professional | | $89.89 | $89.89 | $89.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.00 / $93.19 / $93.19
| Professional | | $89.00 | $93.19 | $93.19 |
- 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
- $76.41 / $89.89 / $89.89
| Professional | | $76.41 | $89.89 | $89.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.00 / $89.00 / $97.90
| Professional | | $89.00 | $89.00 | $97.90 |