- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $538.09 / $538.09 / $538.09
| Professional | | $538.09 | $538.09 | $538.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,471.58 / $1,471.58 / $1,471.58
| Facility | | $1,471.58 | $1,471.58 | $1,471.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.38 / $888.38 / $2,037.66
| Professional | | $888.38 | $888.38 | $2,037.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,852.42 / $1,939.71 / $1,939.71
| Professional | | $1,852.42 | $1,939.71 | $1,939.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.45 / $1,852.42 / $2,593.39
| Professional | | $1,111.45 | $1,852.42 | $2,593.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.42 / $1,471.58 / $2,037.66
| Professional | | $1,048.42 | $1,471.58 | $2,037.66 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.12 / $1,492.19 / $1,763.16
| Professional | | $810.12 | $1,492.19 | $1,763.16 |