- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $579.24 / $579.24 / $579.24
| Professional | | $579.24 | $579.24 | $579.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,403.31 / $1,403.31 / $1,403.31
| Facility | | $1,403.31 | $1,403.31 | $1,403.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.00 / $895.00 / $1,943.13
| Professional | | $895.00 | $895.00 | $1,943.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,766.48 / $1,849.72 / $1,849.72
| Professional | | $1,766.48 | $1,849.72 | $1,849.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.89 / $1,766.48 / $2,473.07
| Professional | | $1,059.89 | $1,766.48 | $2,473.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.48 / $1,403.31 / $1,943.13
| Professional | | $1,093.48 | $1,403.31 | $1,943.13 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.54 / $1,422.96 / $1,681.36
| Professional | | $772.54 | $1,422.96 | $1,681.36 |