- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $870.96 / $2,089.30
| Professional | | $707.95 | $870.96 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,071.52 / $3,467.37
| Professional | | $851.14 | $1,071.52 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,258.93 / $1,412.54
| Professional | | $1,096.48 | $1,258.93 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $933.25 / $1,096.48
| Professional | | $776.25 | $933.25 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,047.13 / $1,445.44
| Professional | | $758.58 | $1,047.13 | $1,445.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $1,096.48
| Professional | | $794.33 | $1,071.52 | $1,096.48 |