- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.37 / $397.86 / $462.58
| Professional | | $290.37 | $397.86 | $462.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.12 / $551.20 / $565.29
| Professional | | $409.12 | $551.20 | $565.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.35 / $708.79 / $796.57
| Professional | | $615.35 | $708.79 | $796.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.97 / $510.33 / $633.12
| Professional | | $400.97 | $510.33 | $633.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $461.27 / $566.11 / $803.27
| Professional | | $461.27 | $566.11 | $803.27 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.27 / $1,958.52 / $5,287.00
| Professional | | $446.27 | $1,958.52 | $5,287.00 |