- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.46 / $1,148.46 / $1,148.46
| Professional | | $1,148.46 | $1,148.46 | $1,148.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.32 / $1,239.05 / $1,486.86
| Professional | | $955.32 | $1,239.05 | $1,486.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.09 / $1,650.57 / $2,072.80
| Professional | | $1,469.09 | $1,650.57 | $2,072.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.35 / $1,189.49 / $1,387.74
| Professional | | $1,090.35 | $1,189.49 | $1,387.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.06 / $1,239.05 / $1,883.55
| Professional | | $1,011.06 | $1,239.05 | $1,883.55 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.90 / $3,692.19 / $9,324.00
| Professional | | $1,181.90 | $3,692.19 | $9,324.00 |