- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.55 / $630.55 / $769.02
| Professional | | $630.55 | $630.55 | $769.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.14 / $1,020.95 / $1,225.14
| Professional | | $819.14 | $1,020.95 | $1,225.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.47 / $1,232.32 / $1,417.17
| Professional | | $1,047.47 | $1,232.32 | $1,417.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $721.41 / $898.44 / $1,020.95
| Professional | | $721.41 | $898.44 | $1,020.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.96 / $1,016.47 / $1,311.84
| Professional | | $794.96 | $1,016.47 | $1,311.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.33 / $3,098.10 / $8,000.00
| Professional | | $766.33 | $3,098.10 | $8,000.00 |