- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,776.96 / $1,776.96 / $1,776.96
| Facility | | $1,776.96 | $1,776.96 | $1,776.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.43 / $1,436.52 / $1,787.43
| Professional | | $183.43 | $1,436.52 | $1,787.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,595.30 / $2,717.59 / $3,408.90
| Professional | | $2,595.30 | $2,717.59 | $3,408.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.16 / $167.16 / $1,764.56
| Professional | | $167.16 | $167.16 | $1,764.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.30 / $1,776.96 / $1,820.72
| Professional | | $967.30 | $1,776.96 | $1,820.72 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,857.43 / $1,857.43 / $2,595.30
| Professional | | $1,857.43 | $1,857.43 | $2,595.30 |