- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.29 / $1,157.01 / $1,784.45
| Professional | | $867.29 | $1,157.01 | $1,784.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.48 / $1,330.25 / $1,480.77
| Professional | | $1,085.48 | $1,330.25 | $1,480.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.29 / $1,506.60 / $1,588.54
| Professional | | $150.29 | $1,506.60 | $1,588.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.61 / $1,277.04 / $1,489.88
| Professional | | $1,170.61 | $1,277.04 | $1,489.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $918.13 / $1,330.25 / $1,551.59
| Professional | | $918.13 | $1,330.25 | $1,551.59 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.07 / $1,179.20 / $1,354.37
| Professional | | $724.07 | $1,179.20 | $1,354.37 |