- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $826.94 / $826.94 / $826.94
| Facility | | $826.94 | $826.94 | $826.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.02 / $432.02 / $432.02
| Professional | | $432.02 | $432.02 | $432.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.16 / $576.16 / $576.16
| Professional | | $576.16 | $576.16 | $576.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.22 / $518.42 / $604.83
| Professional | | $475.22 | $518.42 | $604.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.02 / $473.55 / $648.03
| Professional | | $432.02 | $473.55 | $648.03 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.50 / $449.30 / $562.95
| Professional | | $65.50 | $449.30 | $562.95 |