- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.33 / $560.33 / $560.33
| Professional | | $560.33 | $560.33 | $560.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,307.54 / $1,307.54 / $1,307.54
| Facility | | $1,307.54 | $1,307.54 | $1,307.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.33 / $941.33 / $1,810.53
| Professional | | $941.33 | $941.33 | $1,810.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.94 / $1,723.50 / $1,723.50
| Professional | | $1,645.94 | $1,723.50 | $1,723.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.16 / $1,645.94 / $2,304.32
| Professional | | $1,152.16 | $1,645.94 | $2,304.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.06 / $1,307.54 / $1,810.53
| Professional | | $1,147.06 | $1,307.54 | $1,810.53 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.86 / $1,371.30 / $1,566.63
| Professional | | $1,325.86 | $1,371.30 | $1,566.63 |