- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $985.49 / $985.49 / $985.49
| Facility | | $985.49 | $985.49 | $985.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.81 / $200.00 / $865.90
| Professional | | $98.81 | $200.00 | $865.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.75 / $1,719.75 / $1,800.78
| Professional | | $1,719.75 | $1,719.75 | $1,800.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.04 / $105.04 / $105.04
| Professional | | $105.04 | $105.04 | $105.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.47 / $985.49 / $1,009.79
| Professional | | $536.47 | $985.49 | $1,009.79 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.81 / $1,161.81 / $1,161.81
| Professional | | $1,161.81 | $1,161.81 | $1,161.81 |