- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.03 / $1,155.27 / $1,420.88
| Professional | | $991.03 | $1,155.27 | $1,420.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.19 / $1,555.19 / $1,555.19
| Professional | | $1,555.19 | $1,555.19 | $1,555.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,386.22 / $1,594.97 / $1,875.48
| Professional | | $1,386.22 | $1,594.97 | $1,875.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.67 / $1,557.46 / $1,817.03
| Professional | | $1,427.67 | $1,557.46 | $1,817.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.95 / $1,878.33 / $2,058.75
| Professional | | $908.95 | $1,878.33 | $2,058.75 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.55 / $1,064.39 / $1,452.58
| Professional | | $876.55 | $1,064.39 | $1,452.58 |