- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.82 / $306.83 / $416.87
| Professional | | $231.82 | $306.83 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.47 / $418.46 / $760.45
| Professional | | $289.47 | $418.46 | $760.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.57 / $452.34 / $568.37
| Professional | | $387.57 | $452.34 | $568.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.86 / $366.69 / $503.30
| Professional | | $265.86 | $366.69 | $503.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.14 / $443.92 / $575.00
| Professional | | $317.14 | $443.92 | $575.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.48 / $1,402.00 / $3,725.00
| Professional | | $326.48 | $1,402.00 | $3,725.00 |