- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $630.96 / $812.83
| Professional | | $426.58 | $630.96 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $724.44 / $1,071.52
| Professional | | $363.08 | $724.44 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $741.31 / $1,148.15
| Professional | | $602.56 | $741.31 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,023.29 / $1,258.93
| Professional | | $933.25 | $1,023.29 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $812.83 / $954.99
| Professional | | $446.68 | $812.83 | $954.99 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $602.56 / $891.25
| Professional | | $323.59 | $602.56 | $891.25 |