- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.08 / $872.08 / $915.68
| Professional | | $872.08 | $872.08 | $915.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.08 / $872.08 / $872.08
| Professional | | $872.08 | $872.08 | $872.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.73 / $944.52 / $1,064.38
| Professional | | $821.73 | $944.52 | $1,064.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.10 / $584.10 / $584.10
| Professional | | $584.10 | $584.10 | $584.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.39 / $816.27 / $1,308.11
| Professional | | $815.39 | $816.27 | $1,308.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.21 / $226.21 / $235.64
| Professional | | $226.21 | $226.21 | $235.64 |