- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.58 / $444.57 / $1,104.08
| Professional | | $78.58 | $444.57 | $1,104.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.72 / $816.27 / $1,637.68
| Professional | | $88.72 | $816.27 | $1,637.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.80 / $71.14 / $1,506.59
| Professional | | $59.80 | $71.14 | $1,506.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.63 / $988.84 / $1,285.49
| Professional | | $92.63 | $988.84 | $1,285.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.75 / $1,236.05 / $1,671.45
| Professional | | $844.75 | $1,236.05 | $1,671.45 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.20 / $186.43 / $1,479.77
| Professional | | $75.20 | $186.43 | $1,479.77 |