- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.48 / $125.10 / $1,181.53
| Professional | | $73.48 | $125.10 | $1,181.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.29 / $58.29 / $157.16
| Professional | | $58.29 | $58.29 | $157.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $209.42 / $209.42
| Professional | | $200.00 | $209.42 | $209.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.02 / $200.02 / $200.02
| Professional | | $200.02 | $200.02 | $200.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.44 / $77.20 / $178.19
| Professional | | $47.44 | $77.20 | $178.19 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.86 / $135.97 / $400.00
| Professional | | $119.86 | $135.97 | $400.00 |