- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,045.77 / $2,045.77 / $2,045.77
| Facility | | $2,045.77 | $2,045.77 | $2,045.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.18 / $1,219.64 / $2,057.83
| Professional | | $211.18 | $1,219.64 | $2,057.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,988.00 / $3,128.79 / $3,924.75
| Professional | | $2,988.00 | $3,128.79 | $3,924.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.45 / $192.45 / $2,031.49
| Professional | | $192.45 | $192.45 | $2,031.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.59 / $2,045.77 / $2,096.08
| Professional | | $1,113.59 | $2,045.77 | $2,096.08 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,988.00 / $2,988.00 / $2,988.00
| Professional | | $2,988.00 | $2,988.00 | $2,988.00 |