- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $597.86 / $597.86 / $597.86
| Facility | | $597.86 | $597.86 | $597.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.95 / $232.12 / $525.30
| Professional | | $59.95 | $232.12 | $525.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,229.70 / $1,229.70 / $1,287.64
| Professional | | $1,229.70 | $1,229.70 | $1,287.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.36 / $74.36 / $74.36
| Professional | | $74.36 | $74.36 | $74.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.37 / $597.86 / $612.44
| Professional | | $325.37 | $597.86 | $612.44 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.83 / $830.83 / $830.83
| Professional | | $830.83 | $830.83 | $830.83 |