- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $780.25 / $780.25 / $780.25
| Facility | | $780.25 | $780.25 | $780.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.23 / $134.00 / $685.56
| Professional | | $78.23 | $134.00 | $685.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,439.85 / $1,439.85 / $1,507.70
| Professional | | $1,439.85 | $1,439.85 | $1,507.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.20 / $83.20 / $83.20
| Professional | | $83.20 | $83.20 | $83.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.69 / $780.25 / $799.38
| Professional | | $424.69 | $780.25 | $799.38 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.92 / $972.92 / $972.92
| Professional | | $972.92 | $972.92 | $972.92 |