- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.94 / $459.94 / $459.94
| Professional | | $459.94 | $459.94 | $459.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $985.99 / $985.99 / $985.99
| Facility | | $985.99 | $985.99 | $985.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.43 / $895.43 / $1,365.29
| Professional | | $895.43 | $895.43 | $1,365.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.17 / $1,299.65 / $1,299.65
| Professional | | $1,241.17 | $1,299.65 | $1,299.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.70 / $1,241.17 / $1,737.64
| Professional | | $744.70 | $1,241.17 | $1,737.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.18 / $985.99 / $1,365.29
| Professional | | $851.18 | $985.99 | $1,365.29 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.80 / $999.80 / $1,181.35
| Professional | | $542.80 | $999.80 | $1,181.35 |