- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.09 / $1,148.83 / $1,988.01
| Professional | | $1,029.09 | $1,148.83 | $1,988.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,277.84 / $1,628.94 / $1,628.94
| Professional | | $1,277.84 | $1,628.94 | $1,628.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,341.93 / $1,507.70 / $1,779.09
| Professional | | $1,341.93 | $1,507.70 | $1,779.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.47 / $1,563.78 / $1,824.41
| Professional | | $1,433.47 | $1,563.78 | $1,824.41 |
- 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
- $1,329.21 / $1,628.94 / $2,032.11
| Professional | | $1,329.21 | $1,628.94 | $2,032.11 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.27 / $1,170.08 / $2,015.76
| Professional | | $29.27 | $1,170.08 | $2,015.76 |