- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.72 / $1,094.72 / $1,094.72
| Professional | | $1,094.72 | $1,094.72 | $1,094.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.22 / $1,446.41 / $1,735.70
| Professional | | $1,121.22 | $1,446.41 | $1,735.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,609.05 / $1,807.82 / $8,430.00
| Professional | | $1,609.05 | $1,807.82 | $8,430.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.83 / $1,388.56 / $1,619.98
| Professional | | $1,272.83 | $1,388.56 | $1,619.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.27 / $1,446.41 / $1,932.56
| Professional | | $1,180.27 | $1,446.41 | $1,932.56 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.98 / $1,099.57 / $2,118.00
| Professional | | $206.98 | $1,099.57 | $2,118.00 |