- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.73 / $830.73 / $830.73
| Professional | | $830.73 | $830.73 | $830.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,951.13 / $1,951.13 / $1,951.13
| Facility | | $1,951.13 | $1,951.13 | $1,951.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.16 / $1,747.16 / $2,701.67
| Professional | | $1,747.16 | $1,747.16 | $2,701.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,456.06 / $2,571.79 / $2,571.79
| Professional | | $2,456.06 | $2,571.79 | $2,571.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.64 / $2,456.06 / $3,438.48
| Professional | | $1,473.64 | $2,456.06 | $3,438.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,711.66 / $1,951.13 / $2,701.67
| Professional | | $1,711.66 | $1,951.13 | $2,701.67 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.14 / $1,534.48 / $2,337.71
| Professional | | $1,074.14 | $1,534.48 | $2,337.71 |