- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.31 / $300.48 / $302.33
| Professional | | $212.31 | $300.48 | $302.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.70 / $302.33 / $362.79
| Professional | | $246.70 | $302.33 | $362.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.04 / $274.29 / $327.44
| Professional | | $253.04 | $274.29 | $327.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.05 / $290.23 / $338.60
| Professional | | $266.05 | $290.23 | $338.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,078.00 / $1,078.00 / $1,078.00
| Facility | | $1,078.00 | $1,078.00 | $1,078.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.70 / $302.33 / $499.18
| Professional | | $246.70 | $302.33 | $499.18 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.19 / $232.19 / $316.87
| Professional | | $232.19 | $232.19 | $316.87 |