- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $467.74 / $676.08
| Professional | | $371.54 | $467.74 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $512.86 / $954.99
| Professional | | $407.38 | $512.86 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $741.31 / $812.83
| Professional | | $537.03 | $741.31 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $478.63 / $562.34
| Professional | | $416.87 | $478.63 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $660.69 / $812.83
| Professional | | $416.87 | $660.69 | $812.83 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $794.33
| Professional | | $741.31 | $741.31 | $794.33 |