- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.55 / $569.55 / $569.55
| Professional | | $569.55 | $569.55 | $569.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,231.25 / $1,231.25 / $1,231.25
| Facility | | $1,231.25 | $1,231.25 | $1,231.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.22 / $1,704.89 / $1,704.89
| Professional | | $1,111.22 | $1,704.89 | $1,704.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.90 / $1,622.93 / $1,622.93
| Professional | | $1,549.90 | $1,622.93 | $1,622.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.94 / $1,549.90 / $2,169.86
| Professional | | $929.94 | $1,549.90 | $2,169.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.66 / $1,231.25 / $1,704.89
| Professional | | $940.66 | $1,231.25 | $1,704.89 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.49 / $1,291.28 / $1,475.21
| Professional | | $1,248.49 | $1,291.28 | $1,475.21 |