- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.51 / $186.51 / $186.51
| Professional | | $186.51 | $186.51 | $186.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $771.61 / $771.61 / $771.61
| Facility | | $771.61 | $771.61 | $771.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.03 / $331.03 / $1,068.42
| Professional | | $331.03 | $331.03 | $1,068.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.29 / $1,017.06 / $1,017.06
| Professional | | $971.29 | $1,017.06 | $1,017.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.77 / $971.29 / $1,359.81
| Professional | | $582.77 | $971.29 | $1,359.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.49 / $771.61 / $1,068.42
| Professional | | $440.49 | $771.61 | $1,068.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.77 / $782.41 / $924.49
| Professional | | $424.77 | $782.41 | $924.49 |