- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,310.39 / $1,310.39 / $1,310.39
| Facility | | $1,310.39 | $1,310.39 | $1,310.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.11 / $504.00 / $2,146.94
| Professional | | $141.11 | $504.00 | $2,146.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.20 / $1,947.85 / $2,420.25
| Professional | | $1,860.20 | $1,947.85 | $2,420.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,509.65 / $1,509.65 / $1,509.65
| Professional | | $1,509.65 | $1,509.65 | $1,509.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.59 / $1,310.39 / $1,495.00
| Professional | | $839.59 | $1,310.39 | $1,495.00 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,860.20 / $1,860.20 / $1,860.20
| Professional | | $1,860.20 | $1,860.20 | $1,860.20 |