- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $489.78 / $794.33
| Professional | | $331.13 | $489.78 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $457.09 / $691.83
| Professional | | $354.81 | $457.09 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $575.44 / $741.31
| Professional | | $549.54 | $575.44 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $575.44 / $724.44
| Professional | | $407.38 | $575.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $537.03 / $741.31
| Professional | | $416.87 | $537.03 | $741.31 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $501.19 / $741.31
| Professional | | $93.33 | $501.19 | $741.31 |