- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.14 / $612.14 / $612.14
| Professional | | $612.14 | $612.14 | $612.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,428.46 / $1,428.46 / $1,428.46
| Facility | | $1,428.46 | $1,428.46 | $1,428.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.38 / $1,977.94 / $1,977.94
| Professional | | $1,028.38 | $1,977.94 | $1,977.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,798.13 / $1,882.86 / $1,882.86
| Professional | | $1,798.13 | $1,882.86 | $1,882.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,078.88 / $1,798.13 / $2,517.38
| Professional | | $1,078.88 | $1,798.13 | $2,517.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.13 / $1,428.46 / $1,977.94
| Professional | | $1,253.13 | $1,428.46 | $1,977.94 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.47 / $1,498.11 / $1,711.49
| Professional | | $1,448.47 | $1,498.11 | $1,711.49 |