- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.41 / $617.41 / $1,266.27
| Professional | | $617.41 | $617.41 | $1,266.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.70 / $1,080.70 / $1,080.70
| Professional | | $1,080.70 | $1,080.70 | $1,080.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.00 / $1,211.52 / $1,211.52
| Professional | | $1,157.00 | $1,211.52 | $1,211.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.00 / $670.00 / $670.00
| Professional | | $670.00 | $670.00 | $670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.60 / $1,080.70 / $1,080.70
| Professional | | $918.60 | $1,080.70 | $1,080.70 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.16 / $1,230.16 / $1,230.16
| Professional | | $1,230.16 | $1,230.16 | $1,230.16 |