- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $467.74 / $1,995.26
| Professional | | $162.18 | $467.74 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $1,548.82 / $1,659.59
| Professional | | $204.17 | $1,548.82 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $346.74 / $7,413.10
| Professional | | $288.40 | $346.74 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $1,318.26 / $1,621.81
| Professional | | $165.96 | $1,318.26 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $1,258.93 / $2,089.30
| Professional | | $218.78 | $1,258.93 | $2,089.30 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $1,258.93 / $2,691.53
| Professional | | $208.93 | $1,258.93 | $2,691.53 |