- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.47 / $388.99 / $497.89
| Professional | | $228.47 | $388.99 | $497.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.23 / $213.23 / $606.12
| Professional | | $213.23 | $213.23 | $606.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.00 / $1,204.19 / $1,204.19
| Professional | | $1,150.00 | $1,204.19 | $1,204.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.43 / $771.43 / $771.43
| Professional | | $771.43 | $771.43 | $771.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.53 / $545.51 / $841.50
| Professional | | $173.53 | $545.51 | $841.50 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.16 / $459.08 / $524.47
| Professional | | $413.16 | $459.08 | $524.47 |