- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.70 / $1,630.80 / $4,240.79
| Professional | | $1,101.70 | $1,630.80 | $4,240.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.93 / $1,238.93 / $1,238.93
| Professional | | $1,238.93 | $1,238.93 | $1,238.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.63 / $1,214.63 / $1,433.26
| Professional | | $1,214.63 | $1,214.63 | $1,433.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.89 / $1,214.63 / $1,821.95
| Professional | | $1,136.89 | $1,214.63 | $1,821.95 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.70 / $1,107.70 / $1,107.70
| Professional | | $1,107.70 | $1,107.70 | $1,107.70 |