- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.58 / $473.58 / $473.58
| Professional | | $473.58 | $473.58 | $473.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,171.88 / $1,171.88 / $1,171.88
| Facility | | $1,171.88 | $1,171.88 | $1,171.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.11 / $1,622.67 / $1,622.67
| Professional | | $908.11 | $1,622.67 | $1,622.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.15 / $1,544.66 / $1,544.66
| Professional | | $1,475.15 | $1,544.66 | $1,544.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.09 / $1,475.15 / $2,065.21
| Professional | | $885.09 | $1,475.15 | $2,065.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.83 / $1,171.88 / $1,622.67
| Professional | | $983.83 | $1,171.88 | $1,622.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.14 / $1,188.29 / $1,404.07
| Professional | | $645.14 | $1,188.29 | $1,404.07 |