- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $1,348.96 / $2,344.23
| Professional | | $407.38 | $1,348.96 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,778.28 / $2,630.27
| Professional | | $616.60 | $1,778.28 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,380.38 / $7,079.46
| Professional | | $977.24 | $1,380.38 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,548.82 / $1,949.84
| Professional | | $398.11 | $1,548.82 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,479.11 / $3,801.89
| Professional | | $489.78 | $1,479.11 | $3,801.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $1,148.15 / $4,466.84
| Professional | | $263.03 | $1,148.15 | $4,466.84 |