- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.68 / $1,036.68 / $1,036.68
| Facility | | $1,036.68 | $1,036.68 | $1,036.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.29 / $551.29 / $727.69
| Professional | | $551.29 | $551.29 | $727.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.89 / $529.89 / $529.89
| Professional | | $529.89 | $529.89 | $529.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.80 / $767.80 / $767.80
| Professional | | $767.80 | $767.80 | $767.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.88 / $635.87 / $741.84
| Professional | | $582.88 | $635.87 | $741.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $529.89 / $631.07 / $794.84
| Professional | | $529.89 | $631.07 | $794.84 |
University Health Alliance - Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.54 / $640.09 / $678.40
| Professional | | $523.54 | $640.09 | $678.40 |