- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.38 / $446.38 / $690.15
| Professional | | $446.38 | $446.38 | $690.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.92 / $782.31 / $938.78
| Professional | | $675.92 | $782.31 | $938.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $623.62 / $753.01 / $3,857.00
| Professional | | $623.62 | $753.01 | $3,857.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.40 / $625.85 / $782.31
| Professional | | $446.40 | $625.85 | $782.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $539.16 / $675.92 / $785.79
| Professional | | $539.16 | $675.92 | $785.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.96 / $3,098.10 / $8,000.00
| Professional | | $513.96 | $3,098.10 | $8,000.00 |