- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,391.03 / $2,391.03 / $2,391.03
| Facility | | $2,391.03 | $2,391.03 | $2,391.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.39 / $2,100.86 / $2,160.00
| Professional | | $259.39 | $2,100.86 | $2,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,324.95 / $4,324.95 / $4,528.74
| Professional | | $4,324.95 | $4,324.95 | $4,528.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.68 / $235.68 / $2,266.51
| Professional | | $235.68 | $235.68 | $2,266.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.30 / $1,301.30 / $2,449.40
| Professional | | $1,301.30 | $1,301.30 | $2,449.40 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,292.80 / $3,292.80 / $3,292.80
| Professional | | $3,292.80 | $3,292.80 | $3,292.80 |