- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,567.57 / $1,567.57 / $1,567.57
| Facility | | $1,567.57 | $1,567.57 | $1,567.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.82 / $975.26 / $1,576.98
| Professional | | $161.82 | $975.26 | $1,576.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,289.69 / $2,397.59 / $3,007.35
| Professional | | $2,289.69 | $2,397.59 | $3,007.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,556.79 / $1,556.79 / $1,556.79
| Professional | | $1,556.79 | $1,556.79 | $1,556.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.22 / $1,567.57 / $1,605.99
| Professional | | $853.22 | $1,567.57 | $1,605.99 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,289.69 / $2,289.69 / $2,289.69
| Professional | | $2,289.69 | $2,289.69 | $2,289.69 |