- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.02 / $335.62 / $519.62
| Professional | | $240.02 | $335.62 | $519.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.63 / $457.45 / $548.94
| Professional | | $351.63 | $457.45 | $548.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.06 / $509.02 / $2,077.00
| Professional | | $453.06 | $509.02 | $2,077.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.50 / $402.56 / $475.75
| Professional | | $353.50 | $402.56 | $475.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.78 / $454.82 / $546.29
| Professional | | $333.78 | $454.82 | $546.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.73 / $346.64 / $477.82
| Professional | | $59.73 | $346.64 | $477.82 |