- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $854.62 / $854.62 / $854.62
| Facility | | $854.62 | $854.62 | $854.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.66 / $750.90 / $766.64
| Professional | | $85.66 | $750.90 | $766.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,588.50 / $1,588.50 / $1,663.35
| Professional | | $1,588.50 | $1,588.50 | $1,663.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.55 / $86.55 / $86.55
| Professional | | $86.55 | $86.55 | $86.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $464.95 / $854.62 / $875.17
| Professional | | $464.95 | $854.62 | $875.17 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.28 / $1,073.28 / $1,073.28
| Professional | | $1,073.28 | $1,073.28 | $1,073.28 |