- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.89 / $1,220.80 / $3,889.00
| Professional | | $768.89 | $1,220.80 | $3,889.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Professional | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,214.63 / $1,214.63
| Professional | | $1,214.63 | $1,214.63 | $1,214.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.00 / $1,171.00 / $1,821.95
| Professional | | $650.00 | $1,171.00 | $1,821.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $749.44 / $910.04 / $1,070.63
| Professional | | $749.44 | $910.04 | $1,070.63 |