- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.53 / $759.31 / $3,810.47
| Professional | | $615.53 | $759.31 | $3,810.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.63 / $938.20 / $2,084.78
| Professional | | $735.63 | $938.20 | $2,084.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.40 / $1,053.19 / $1,211.17
| Professional | | $937.40 | $1,053.19 | $1,211.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.59 / $900.67 / $1,050.78
| Professional | | $795.59 | $900.67 | $1,050.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.18 / $811.66 / $1,245.54
| Professional | | $660.18 | $811.66 | $1,245.54 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $694.17 / $931.00 / $947.34
| Professional | | $694.17 | $931.00 | $947.34 |