- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.79 / $63.58 / $91.98
| Professional | | $57.79 | $63.58 | $91.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.45 / $67.45 / $128.59
| Professional | | $67.45 | $67.45 | $128.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.00 / $231.41 / $231.41
| Professional | | $221.00 | $231.41 | $231.41 |
- 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
- $171.70 / $202.00 / $202.00
| Professional | | $171.70 | $202.00 | $202.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.33 / $275.33 / $302.86
| Professional | | $275.33 | $275.33 | $302.86 |