- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.15 / $1,838.67 / $8,357.09
| Professional | | $1,129.15 | $1,838.67 | $8,357.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.83 / $1,465.68 / $1,465.68
| Professional | | $1,245.83 | $1,465.68 | $1,465.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,040.13 / $2,554.46 / $3,100.63
| Professional | | $2,040.13 | $2,554.46 | $3,100.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.26 / $1,302.83 / $1,519.97
| Professional | | $1,118.26 | $1,302.83 | $1,519.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.68 / $2,106.66 / $2,108.75
| Professional | | $1,465.68 | $2,106.66 | $2,108.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.72 / $2,064.53 / $3,517.70
| Professional | | $1,407.72 | $2,064.53 | $3,517.70 |