- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.50 / $279.50 / $279.50
| Professional | | $279.50 | $279.50 | $279.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.08 / $1,071.08 / $1,071.08
| Facility | | $1,071.08 | $1,071.08 | $1,071.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.31 / $663.31 / $1,483.12
| Professional | | $663.31 | $663.31 | $1,483.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.29 / $1,411.82 / $1,411.82
| Professional | | $1,348.29 | $1,411.82 | $1,411.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.97 / $1,348.29 / $1,887.61
| Professional | | $808.97 | $1,348.29 | $1,887.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.65 / $939.62 / $1,483.12
| Professional | | $554.65 | $939.62 | $1,483.12 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.65 / $1,086.09 / $1,283.32
| Professional | | $589.65 | $1,086.09 | $1,283.32 |