- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.08 / $1,462.08 / $1,724.24
| Professional | | $1,462.08 | $1,462.08 | $1,724.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,619.71 / $1,984.94 / $2,381.92
| Professional | | $1,619.71 | $1,984.94 | $2,381.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,911.90 / $2,154.29 / $2,412.17
| Professional | | $1,911.90 | $2,154.29 | $2,412.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,335.05 / $1,746.75 / $1,984.94
| Professional | | $1,335.05 | $1,746.75 | $1,984.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,619.71 / $1,984.94 / $2,611.46
| Professional | | $1,619.71 | $1,984.94 | $2,611.46 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.74 / $1,453.04 / $2,093.46
| Professional | | $263.74 | $1,453.04 | $2,093.46 |