- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.66 / $730.66 / $730.66
| Professional | | $730.66 | $730.66 | $730.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,705.90 / $1,705.90 / $1,705.90
| Facility | | $1,705.90 | $1,705.90 | $1,705.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.79 / $1,317.79 / $2,362.12
| Professional | | $1,317.79 | $1,317.79 | $2,362.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.38 / $2,248.56 / $2,248.56
| Professional | | $2,147.38 | $2,248.56 | $2,248.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.43 / $2,147.38 / $3,006.33
| Professional | | $1,288.43 | $2,147.38 | $3,006.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,206.73 / $1,705.90 / $2,362.12
| Professional | | $1,206.73 | $1,705.90 | $2,362.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $939.11 / $1,729.79 / $2,043.91
| Professional | | $939.11 | $1,729.79 | $2,043.91 |