- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,119.73 / $2,119.73 / $2,119.73
| Facility | | $2,119.73 | $2,119.73 | $2,119.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.80 / $1,406.76 / $2,132.23
| Professional | | $218.80 | $1,406.76 | $2,132.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,095.70 / $3,241.57 / $4,066.05
| Professional | | $3,095.70 | $3,241.57 | $4,066.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.41 / $199.41 / $2,104.94
| Professional | | $199.41 | $199.41 | $2,104.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,153.67 / $2,119.73 / $2,171.51
| Professional | | $1,153.67 | $2,119.73 | $2,171.51 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,095.70 / $3,095.70 / $3,095.70
| Professional | | $3,095.70 | $3,095.70 | $3,095.70 |