- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.55 / $785.55 / $785.55
| Professional | | $785.55 | $785.55 | $785.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.18 / $1,698.18 / $1,698.18
| Facility | | $1,698.18 | $1,698.18 | $1,698.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.54 / $2,351.42 / $2,351.42
| Professional | | $1,222.54 | $2,351.42 | $2,351.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.66 / $2,238.39 / $2,238.39
| Professional | | $2,137.66 | $2,238.39 | $2,238.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.36 / $2,137.66 / $2,992.72
| Professional | | $1,496.36 | $2,137.66 | $2,992.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,489.73 / $1,698.18 / $2,351.42
| Professional | | $1,489.73 | $1,698.18 | $2,351.42 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,489.73 / $1,780.98 / $2,034.66
| Professional | | $1,489.73 | $1,780.98 | $2,034.66 |