- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $171.96 / $171.96
| Professional | | $134.90 | $171.96 | $171.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $699.93 / $699.93 / $699.93
| Professional | | $699.93 | $699.93 | $699.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.00 / $859.69 / $859.69
| Professional | | $821.00 | $859.69 | $859.69 |
- 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
- $594.94 / $699.93 / $699.93
| Professional | | $594.94 | $699.93 | $699.93 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.33 / $705.33 / $775.86
| Professional | | $705.33 | $705.33 | $775.86 |