- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.90 / $1,354.22 / $1,708.16
| Professional | | $975.90 | $1,354.22 | $1,708.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $742.34 / $1,827.34
| Professional | | $742.34 | $742.34 | $1,827.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,400.00 / $5,654.45 / $5,654.45
| Professional | | $5,400.00 | $5,654.45 | $5,654.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,325.71 / $2,325.71 / $2,325.71
| Professional | | $2,325.71 | $2,325.71 | $2,325.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.12 / $1,827.34 / $4,059.00
| Professional | | $604.12 | $1,827.34 | $4,059.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.18 / $1,384.04 / $1,581.18
| Professional | | $1,247.18 | $1,384.04 | $1,581.18 |