- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,653.68 / $4,653.68 / $4,653.68
| Facility | | $4,653.68 | $4,653.68 | $4,653.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.34 / $2,900.00 / $4,680.96
| Professional | | $480.34 | $2,900.00 | $4,680.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,796.50 / $7,116.75 / $8,926.79
| Professional | | $6,796.50 | $7,116.75 | $8,926.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.47 / $413.47 / $4,621.03
| Professional | | $413.47 | $413.47 | $4,621.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,532.81 / $4,653.68 / $4,767.43
| Professional | | $2,532.81 | $4,653.68 | $4,767.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,796.50 / $6,796.50 / $6,796.50
| Professional | | $6,796.50 | $6,796.50 | $6,796.50 |