- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $2,884.03 / $5,888.44
| Professional | | $776.25 | $2,884.03 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $4,365.16 / $6,025.60
| Professional | | $1,071.52 | $4,365.16 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $6,760.83
| Professional | | $1,288.25 | $1,584.89 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $4,570.88 / $5,754.40
| Professional | | $776.25 | $4,570.88 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $3,311.31 / $5,370.32
| Professional | | $645.65 | $3,311.31 | $5,370.32 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $9,120.11 / $14,125.38
| Professional | | $933.25 | $9,120.11 | $14,125.38 |