- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $562.34 / $954.99
| Professional | | $389.05 | $562.34 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $776.25
| Professional | | $676.08 | $676.08 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $812.83 / $4,677.35
| Professional | | $660.69 | $812.83 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $724.44 / $870.96
| Professional | | $407.38 | $724.44 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $645.65 / $977.24
| Professional | | $416.87 | $645.65 | $977.24 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $3,311.31 / $7,585.78
| Professional | | $537.03 | $3,311.31 | $7,585.78 |