- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $697.73 / $838.51 / $1,039.81
| Professional | | $697.73 | $838.51 | $1,039.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.18 / $1,217.56 / $4,180.97
| Professional | | $840.18 | $1,217.56 | $4,180.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.66 / $1,109.51 / $1,248.98
| Professional | | $966.66 | $1,109.51 | $1,248.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.71 / $1,178.05 / $1,374.39
| Professional | | $981.71 | $1,178.05 | $1,374.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.81 / $1,036.28 / $1,429.86
| Professional | | $710.81 | $1,036.28 | $1,429.86 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.60 / $902.94 / $1,232.24
| Professional | | $743.60 | $902.94 | $1,232.24 |