- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.20 / $659.78 / $940.52
| Professional | | $121.20 | $659.78 | $940.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.44 / $752.35 / $1,440.74
| Professional | | $139.44 | $752.35 | $1,440.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.86 / $1,043.03 / $1,199.48
| Professional | | $884.86 | $1,043.03 | $1,199.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.19 / $783.03 / $1,096.24
| Professional | | $151.19 | $783.03 | $1,096.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.50 / $978.79 / $1,534.28
| Professional | | $727.50 | $978.79 | $1,534.28 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.84 / $459.50 / $1,683.04
| Professional | | $120.84 | $459.50 | $1,683.04 |