- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $599.04 / $599.04 / $599.04
| Professional | | $599.04 | $599.04 | $599.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,444.93 / $1,444.93 / $1,444.93
| Facility | | $1,444.93 | $1,444.93 | $1,444.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.60 / $2,000.74 / $2,000.74
| Professional | | $1,018.60 | $2,000.74 | $2,000.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,818.85 / $1,904.55 / $1,904.55
| Professional | | $1,818.85 | $1,904.55 | $1,904.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.31 / $1,818.85 / $2,546.39
| Professional | | $1,091.31 | $1,818.85 | $2,546.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.49 / $1,444.93 / $2,000.74
| Professional | | $1,244.49 | $1,444.93 | $2,000.74 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.47 / $1,465.16 / $1,731.21
| Professional | | $795.47 | $1,465.16 | $1,731.21 |