- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $2,951.21 / $4,073.80
| Professional | | $181.97 | $2,951.21 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $4,168.69 / $4,786.30
| Professional | | $208.93 | $4,168.69 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $416.87 / $5,623.41
| Professional | | $338.84 | $416.87 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $4,466.84 / $5,623.41
| Professional | | $204.17 | $4,466.84 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $3,890.45 / $5,370.32
| Professional | | $239.88 | $3,890.45 | $5,370.32 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $9,772.37 / $14,125.38
| Professional | | $741.31 | $9,772.37 | $14,125.38 |