- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.62 / $985.62 / $1,048.41
| Professional | | $985.62 | $985.62 | $1,048.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.73 / $1,277.34 / $1,532.82
| Professional | | $987.73 | $1,277.34 | $1,532.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.32 / $1,638.47 / $8,430.00
| Professional | | $1,458.32 | $1,638.47 | $8,430.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.07 / $1,226.26 / $1,430.63
| Professional | | $1,124.07 | $1,226.26 | $1,430.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.32 / $1,277.34 / $1,741.89
| Professional | | $1,042.32 | $1,277.34 | $1,741.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.43 / $987.11 / $1,782.23
| Professional | | $174.43 | $987.11 | $1,782.23 |