- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.93 / $744.93 / $762.88
| Professional | | $744.93 | $744.93 | $762.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.88 / $762.88 / $859.78
| Professional | | $762.88 | $762.88 | $859.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.73 / $902.02 / $1,086.20
| Professional | | $821.73 | $902.02 | $1,086.20 |
- 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
- $859.78 / $1,869.66 / $2,996.25
| Professional | | $859.78 | $1,869.66 | $2,996.25 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.21 / $226.21 / $235.64
| Professional | | $226.21 | $226.21 | $235.64 |