- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.04 / $608.04 / $608.04
| Professional | | $608.04 | $608.04 | $608.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,374.17 / $2,374.17 / $2,374.17
| Facility | | $2,374.17 | $2,374.17 | $2,374.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.14 / $1,427.14 / $3,287.46
| Professional | | $1,427.14 | $1,427.14 | $3,287.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,988.60 / $3,129.42 / $3,129.42
| Professional | | $2,988.60 | $3,129.42 | $3,129.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,793.16 / $2,988.60 / $4,184.04
| Professional | | $1,793.16 | $2,988.60 | $4,184.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.85 / $2,374.17 / $3,287.46
| Professional | | $1,306.85 | $2,374.17 | $3,287.46 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.01 / $2,407.42 / $2,844.59
| Professional | | $1,307.01 | $2,407.42 | $2,844.59 |