- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.00 / $795.20 / $1,447.66
| Professional | | $600.00 | $795.20 | $1,447.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.91 / $887.52 / $1,281.06
| Professional | | $652.91 | $887.52 | $1,281.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.26 / $1,307.61 / $1,560.98
| Professional | | $1,139.26 | $1,307.61 | $1,560.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.12 / $1,024.84 / $1,195.66
| Professional | | $871.12 | $1,024.84 | $1,195.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.88 / $1,067.55 / $1,658.98
| Professional | | $679.88 | $1,067.55 | $1,658.98 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.46 / $1,023.95 / $1,896.20
| Professional | | $728.46 | $1,023.95 | $1,896.20 |