- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.26 / $324.26 / $324.26
| Professional | | $324.26 | $324.26 | $324.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $941.38 / $941.38 / $941.38
| Facility | | $941.38 | $941.38 | $941.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.34 / $511.34 / $1,303.49
| Professional | | $511.34 | $511.34 | $1,303.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.99 / $1,240.83 / $1,240.83
| Professional | | $1,184.99 | $1,240.83 | $1,240.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.99 / $1,184.99 / $1,658.99
| Professional | | $710.99 | $1,184.99 | $1,658.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $522.73 / $522.73 / $522.73
| Facility | | $522.73 | $522.73 | $522.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.74 / $941.38 / $1,303.49
| Professional | | $624.74 | $941.38 | $1,303.49 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.25 / $954.56 / $1,127.89
| Professional | | $518.25 | $954.56 | $1,127.89 |