- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.78 / $850.50 / $850.50
| Professional | | $750.78 | $850.50 | $850.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.49 / $1,087.10 / $1,087.10
| Professional | | $934.49 | $1,087.10 | $1,087.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,185.05 / $1,331.44 / $1,571.10
| Professional | | $1,185.05 | $1,331.44 | $1,571.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.66 / $1,043.63 / $1,217.57
| Professional | | $956.66 | $1,043.63 | $1,217.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.00 / $2,446.00 / $2,446.00
| Facility | | $2,446.00 | $2,446.00 | $2,446.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.08 / $1,087.10 / $1,456.92
| Professional | | $887.08 | $1,087.10 | $1,456.92 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $801.69 / $1,780.46
| Professional | | $29.27 | $801.69 | $1,780.46 |