- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.78 / $709.51 / $931.42
| Professional | | $29.78 | $709.51 | $931.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.26 / $963.03 / $1,243.01
| Professional | | $546.26 | $963.03 | $1,243.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.29 / $49.73 / $1,163.42
| Professional | | $41.29 | $49.73 | $1,163.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.35 / $963.03 / $1,321.81
| Professional | | $37.35 | $963.03 | $1,321.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.03 / $1,049.79 / $1,298.69
| Professional | | $683.03 | $1,049.79 | $1,298.69 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.76 / $915.76 / $915.76
| Professional | | $915.76 | $915.76 | $915.76 |