- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.76 / $319.76 / $413.87
| Professional | | $190.76 | $319.76 | $413.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $405.36
| Professional | | $175.28 | $175.28 | $405.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.00 / $916.23 / $916.23
| Professional | | $875.00 | $916.23 | $916.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.91 / $515.91 / $515.91
| Professional | | $515.91 | $515.91 | $515.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.63 / $219.10 / $459.62
| Professional | | $142.63 | $219.10 | $459.62 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.02 / $322.68 / $350.75
| Professional | | $307.02 | $322.68 | $350.75 |