- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.61 / $448.61 / $448.61
| Professional | | $448.61 | $448.61 | $448.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $974.48 / $974.48 / $974.48
| Facility | | $974.48 | $974.48 | $974.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.73 / $957.73 / $1,349.34
| Professional | | $957.73 | $957.73 | $1,349.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.67 / $1,284.47 / $1,284.47
| Professional | | $1,226.67 | $1,284.47 | $1,284.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.00 / $1,226.67 / $1,717.34
| Professional | | $736.00 | $1,226.67 | $1,717.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.07 / $974.48 / $1,349.34
| Professional | | $835.07 | $974.48 | $1,349.34 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.47 / $988.12 / $1,167.56
| Professional | | $536.47 | $988.12 | $1,167.56 |