- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.06 / $741.06 / $741.06
| Professional | | $741.06 | $741.06 | $741.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.94 / $629.88 / $1,582.19
| Professional | | $277.94 | $629.88 | $1,582.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.49 / $881.86 / $1,616.90
| Professional | | $122.49 | $881.86 | $1,616.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.15 / $1,406.39 / $1,640.79
| Professional | | $1,207.15 | $1,406.39 | $1,640.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.73 / $1,850.15 / $1,850.15
| Professional | | $861.73 | $1,850.15 | $1,850.15 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.22 / $1,411.15 / $2,788.15
| Professional | | $385.22 | $1,411.15 | $2,788.15 |