- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,581.28 / $1,581.28 / $1,581.28
| Facility | | $1,581.28 | $1,581.28 | $1,581.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.22 / $1,071.00 / $1,590.75
| Professional | | $163.22 | $1,071.00 | $1,590.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,309.50 / $2,418.32 / $3,033.45
| Professional | | $2,309.50 | $2,418.32 | $3,033.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.77 / $148.77 / $1,570.40
| Professional | | $148.77 | $148.77 | $1,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.70 / $1,581.28 / $1,620.06
| Professional | | $860.70 | $1,581.28 | $1,620.06 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,309.50 / $2,309.50 / $2,309.50
| Professional | | $2,309.50 | $2,309.50 | $2,309.50 |