- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $938.55 / $938.55 / $938.55
| Facility | | $938.55 | $938.55 | $938.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.09 / $359.59 / $824.65
| Professional | | $94.09 | $359.59 | $824.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,852.05 / $1,852.05 / $1,939.32
| Professional | | $1,852.05 | $1,852.05 | $1,939.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.84 / $112.84 / $112.84
| Professional | | $112.84 | $112.84 | $112.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.78 / $510.78 / $961.43
| Professional | | $510.78 | $510.78 | $961.43 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.38 / $1,251.38 / $1,251.38
| Professional | | $1,251.38 | $1,251.38 | $1,251.38 |